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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4534_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Contents
- •1.1.9 Laryngeal Atresia
- •1.1.10 Laryngeal Webs
- •1.1.11 Congenital Subglottic Stenosis
- •1.1.12 Laryngeal Cleft
- •1.1.13 Tracheoesophageal Fistula
- •1.1.14 Tracheal Bronchus
- •1.2.2 Mesenchyme Development
- •1.2.4 Lung Development
- •1.2.4.1 Embryonic Stage
- •1.2.4.2 Pseudoglandular Stage
- •1.1.1 Oral Cavity
- •1.1.2 Nasal Cavity
- •1.1.3 Palate
- •1.1.4 Primitive Pharynx
- •1.1.5 Upper Airway Anomalies
- •1.1.6 Cleft Lip/Palate
- •1.1.7 Choanal Atresia
- •1.1.8 Laryngomalacia
- •1.2.4.3 Canalicular Stage
- •1.2.4.4 Saccular Stage
- •1.2.4.5 Alveolar Stage
- •1.2.5 Congenital Respiratory System Defects
- •1.2.5.1 Tracheal Agenesis
- •1.2.5.2 Congenital Tracheal Stenosis
- •1.2.5.3 Lung Agenesis
- •1.2.5.4 Lung Hypoplasia
- •References
- •2.1 Introduction
- •2.2 Nasal Cavity
- •2.2.1 Vestibule
- •2.2.2 Respiratory Mucosa
- •2.2.3 Olfactory Mucosa
- •Supporting Cells
- •Basal Cell
- •Olfactory Receptor Cell (Bipolar Neuron)
- •Brush Cell (Microvillar Cell)
- •2.2.3.2 The Lamina Propria
- •2.2.3.3 Olfactory Glands (Bowman’s Glands)
- •2.3 Paranasal Sinuses
- •2.4 Pharynx
- •2.5 Larynx
- •2.6 Trachea
- •2.6.1.1 Ciliated Columnar Cells
- •2.6.1.2 Goblet Cells
- •2.6.1.3 Brush Cells
- •2.6.1.4 Basal Cells
- •2.6.1.5 Enteroendocrine System Cells (Kulchitsky Cells or DNES Cells)
- •2.6.2 Lamina Propria
- •2.7 Lungs
- •2.7.1 Pleura
- •2.7.2 Bronchi
- •2.7.3 Bronchioles
- •2.7.3.1 Terminal Bronchioles
- •2.7.3.2 Respiratory Bronchioles
- •2.7.4 Ductus Alveolaris
- •2.7.5 Alveoli
- •2.7.5.2 Type II Alveolar Cell (Septal Cell, Large Alveolar Cell)
- •References
- •3.1.1.3 Nerves
- •Ophthalmic Division
- •Maxillary Division
- •Parasympathetic Nerve Supply
- •3.1.1.4 Bony Anatomy
- •3.1.1.5 Cartilaginous Pyramid
- •3.1.1.6 Structure
- •External Nasal Anatomy
- •Internal Nasal Anatomy
- •3.1.2 Nasal Physiology
- •3.1.2.1 Nasal Airflow
- •3.1.2.2 Abnormal Nasal Physiology
- •3.2.1 Larynx Anatomy
- •Cricoid Cartilage
- •Thyroid Cartilage
- •Epiglottis
- •Arytenoid Cartilages
- •Corniculate Cartilages
- •Cuneiform Cartilages
- •Extrinsic Ligaments
- •Intrinsic Ligaments
- •Laryngeal Cavity
- •Piriform Recesses
- •Cricothyroid Muscles
- •Posterior Cricoarytenoid Muscles
- •Lateral Cricoarytenoid Muscles
- •Transverse Arytenoid Muscle
- •Thyroarytenoid Muscles
- •Superior Laryngeal Nerve
- •Arteries
- •Veins
- •Lymphatics
- •Swallowing
- •Respiration
- •Phonation
- •3.2.2.1 Reflex Glottic Closure
- •References
- •4.1 Introduction
- •4.2.1 Choanal Atresia
- •4.2.2 Pyriform Aperture Stenosis
- •4.2.3 Cleft Lip Nasal Deformity
- •4.2.4 Nasolacrimal Duct Cysts
- •4.2.5 Encephaloceles
- •4.3 Craniofacial Anomalies
- •4.3.1 Pierre Robin Syndrome
- •4.3.2 Treacher-Collins Syndrome
- •4.3.3 Crouzon Syndrome
- •4.3.4 Down Syndrome
- •4.3.5 Apert Syndrome
- •4.4.1 Thyroglossal Duct Cyst
- •4.4.2 Laryngomalacia
- •4.4.3 Vocal Fold Paralysis
- •4.4.5 Subglottic Stenosis
- •4.4.6 Subglottic Hemangioma
- •4.4.7 Laryngeal Cysts
- •4.4.8 Laryngeal Cleft
- •4.5 Conclusion
- •References
- •5.1 Innate Immunity
- •5.2 Adaptive Immunity
- •References
- •6.1 Introduction
- •6.2 Innate Immunity
- •6.3 Adaptive Immunity
- •References
- •7.1 Introduction
- •References
- •8: Respiratory Microbiome
- •8.1 Introduction
- •8.2.1 Childhood Asthma
- •8.2.2 Asthma Exacerbation
- •8.3 Bacteriome
- •8.4 Virome
- •8.5 Mycobiome
- •References
- •9.1 Introduction
- •References
- •10.1 Introduction
- •10.3.3 The Appointment Process, Explained
- •10.3.5 Parental Involvement
- •10.4 Coordinating Care When Your Child Is Ill
- •10.4.3 Exhibit Cohesion
- •10.6 Conclusion
- •References
- •11.1 Introduction
- •11.2 Nasal Cavity
- •11.2.1 Choanal Atresia
- •11.2.2 Rhinosinusitis
- •11.2.4 Juvenile Nasopharyngeal Angiofibroma
- •11.3 Pharynx
- •11.4 Nasopharynx
- •11.4.1 Adenoid Hypertrophy
- •11.4.2 Nasopharyngeal Carcinoma
- •11.5 Oropharynx
- •11.5.1 Thyroglossal Duct Cyst
- •11.6 Hypopharynx
- •11.6.1 Retropharyngeal Abscess
- •11.6.2 Lymphatic Malformation
- •11.6.4 Lymphoma
- •11.6.5 Rhabdomyosarcoma
- •11.7 Larynx
- •11.7.1 Subglottic Stenosis
- •11.7.2 Laryngotracheal Papillomatozis
- •11.7.3 Croup
- •11.7.4 Epiglottitis
- •11.7.5 Foreign Body Aspiration
- •References
- •12.2.1 Plain Radiography
- •12.2.1.1 The Thymus
- •Tracheal Buckling
- •Hilum
- •Diaphragm
- •Mediastinal Borders
- •Lung Opacities
- •Cystic Lung Diseases
- •Pulmonary İnterstitial Emphysema (PIE)
- •Unilateral Hyperlucent Lung
- •12.2.2 Fluoroscopy
- •12.2.3 Ultrasound
- •12.2.4 Computed Tomography
- •12.2.5 Magnetic Resonance Imaging (MRI)
- •12.2.6 Angiography
- •12.2.7 Positron Emission Tomography (PET)
- •12.3 Conclusion
- •References
- •13.1 Introduction
- •13.2 Nasal Diagnostic Procedures
- •13.2.1 Indications
- •13.2.2 Contraindications
- •13.2.3 Anatomical Features
- •13.2.4 Technical Considerations
- •13.2.5 Technique
- •13.2.5.1 First Pass
- •13.2.5.2 Second Pass
- •13.2.5.3 Third Pass
- •13.3 Flexible Laryngoscopy
- •13.4 Direct Laryngoscopy
- •13.5 Video Laryngoscopy
- •13.5.1 Indications
- •13.5.2 Contraindications
- •13.5.3 Outcomes
- •13.5.4 Equipment
- •13.5.5 Approach Considerations
- •References
- •14.1 Upper Airways
- •14.2.3 Laryngeal Pathologıes
- •References
- •15.1 Introduction
- •15.2 Airway Measurements
- •References
- •16.1 Introduction
- •16.2 Background
- •References
- •17: Allergen Testing: Purpose, Procedure, Interpretation
- •17.1 Introduction
- •17.2 Tests
- •17.2.1 Skin Tests
- •17.2.3 Component Resolved Diagnosis (CRD)
- •17.2.4 Tryptase
- •17.2.5 Basophil Activation Test (BAT)
- •17.2.6 Provocation Tests
- •17.2.7 Nasal sIgE
- •17.2.8 Nasal Smear Eosinophilia
- •17.2.9 Eosinophilic Cationic Protein (ECP)
- •References
- •18: Smell Testing: Purpose, Procedure, Interpretation
- •18.1 Introduction
- •18.2 Possible Olfactory Disorder Diagnosis
- •18.2.1 Conductive Defects
- •18.2.3 Inherited Disorders
- •18.2.3.1 Hormonal Disturbances
- •18.4 Odor Threshold Tests
- •18.8.1 Butanol Threshold Test
- •18.8.1.1 The Penn State University Odor Identification Exam
- •18.8.2 Cross-Cultural Smell Identification Test
- •18.8.3 Sniffin’ Sticks
- •References
- •19: Taste Testing: Purpose, Procedure, Interpretation
- •19.1 Introduction
- •19.2 Definitions
- •19.2.1 Taste Dysfunction Abnormalities
- •19.4.1 Taste Dysfunction
- •19.4.2 COVID-19
- •19.5 Taste Disorder Diagnosis
- •19.6.2 Magnitude Matching
- •19.6.3 Spatial Test
- •References
- •20.1 Introduction
- •20.2 Primary Otalgia Causes
- •20.2.1 Auricle
- •20.2.1.1 Infections
- •20.2.1.2 Trauma
- •20.2.1.3 Allergic Angioedema
- •20.2.1.4 Thermal Damage
- •20.2.2 External Auditory Canal
- •20.2.2.1 Otitis Externa
- •20.2.2.2 Malignant Otitis Externa
- •20.2.2.3 Eczematous Dermatitis
- •20.2.2.4 Furunculosis
- •20.2.2.5 Foreign Body
- •20.2.2.6 Cerumen Impaction
- •20.2.2.7 Tumors
- •20.2.3 Middle Ear
- •20.2.3.1 Acute Otitis Media
- •20.2.3.3 Eustachian Tube Dysfunction
- •20.2.3.4 Cholesteatoma
- •20.2.3.5 Trauma
- •20.3 Secondary Otalgia Causes
- •20.3.1 Oropharyngeal Infections
- •20.3.2 Dental Causes
- •20.3.3 Auricular Lymphadenitis
- •20.3.4 Neck Abscess
- •20.3.5 Parotitis
- •20.3.6 Temporomandibular Joint Dysfunction
- •20.3.7 Sinusitis
- •20.4 Differential Diagnosis
- •References
- •21.1 Introduction
- •21.2 Bacterial Otitis Externa
- •21.3 Acute Otitis Media
- •21.4 Chronic Suppurative Otitis Media
- •21.5 Foreign Body
- •21.5.1 Cerumen
- •21.5.2 Tympanostomy Tube Drainage
- •21.5.3 Traumatic Cerebrospinal Fluid Otorrhea
- •21.5.5 Necrotizing Otitis Externa (Malignant External Otitis)
- •21.5.6 Neoplasms
- •21.5.7 Polyps
- •21.5.8 Otomycosis
- •21.5.9 First Branchial Cleft Cysts
- •21.5.10 Cholesteatoma
- •21.5.11 Spontaneous Cerebral Spinal Fluid Otorrhea
- •References
- •22.1 Introduction
- •22.4 Congenital Causes
- •22.4.1 Choanal Atresia
- •22.4.2 Pyriform Apertura Stenosis
- •22.4.3 Nasal Midline Congenital Masses
- •22.4.3.1 Nasal Dermoid Cyst
- •22.4.3.2 Nasal Glioma
- •22.4.3.3 Encephalocele (Encephalo-Meningocele)
- •Differential Diagnosis
- •22.4.3.4 Nasolacrimal Duct Cyst (Dacryocystocele)
- •22.5 Infectious Causes
- •22.5.1.1 Rhinitis Etiology
- •22.5.2 Neonatal Rhinitis
- •22.5.3 Bacterial or Viral Rhinitis
- •22.5.4 Iatrogenic Rhinitis
- •22.5.5 Infectious Rhinitis (Rhinosinusitis)
- •22.6 Adenoid Hypertrophy
- •22.7 Inflammatory Causes
- •22.7.1 Allergic Rhinitis
- •22.7.2 Nonallergic Rhinitis
- •22.7.3 Eosinophilic Nonallergic Rhinitis (NARES)
- •22.7.4 Nasal Polyp
- •22.7.5 Antrochoanal Polyp
- •22.7.6 Inferior Turbinate Hypertrophy
- •22.8 Neoplasia
- •22.8.1 Benign Tumors (Juvenile Nasopharyngeal Angiofibroma)
- •22.8.2 Malignant Tumors
- •22.9 Systemic Causes
- •22.9.1 Cystic Fibrosis
- •22.9.2 Primary Ciliary Dyskinesia
- •22.10 Trauma/Iatrogenic Causes
- •22.10.1 Nasal Trauma-Septal Hematoma
- •22.10.2 Septum Deviation
- •22.10.3 Nasal Foreign Bodies
- •References
- •23.1 Introduction
- •23.2 Pathophysiology
- •23.3 Allergic Rhinitis
- •23.4 Non-allergic Rhinitis
- •23.5 Infectious Rhinitis
- •23.6.1 Vasomotor Rhinitis
- •23.7 Evaluation
- •23.8 Diagnosis
- •23.9 Treatment
- •23.10 Prognosis
- •23.11 Conclusion
- •References
- •24.1 Introduction
- •24.2 Pathogenesis
- •24.3 Diagnosis
- •24.3.1 History
- •24.3.2 Examination
- •24.4 Differential Diagnoses
- •24.5 CSF Rhinorrhea
- •24.5.1 CSF Physiology
- •24.5.1.1 Pathogenesis
- •24.6 Diagnosis
- •24.6.1 Chemical Diagnosis
- •24.6.2 Imaging Diagnosis
- •24.7 Treatment
- •24.7.1 Surgical Technique
- •References
- •25.1 Introduction
- •25.1.1 Waldeyer Ring
- •25.3 Anatomy
- •25.3.1 Lymphatic Drainage
- •25.3.1.1 Nerve Supply
- •25.6 Tonsillary Hypertrophy
- •25.7 Physical Examination
- •25.8.1 Obstructive Sleep Apnea
- •References
- •26.1 Introduction
- •26.5 Halitosis Physiopathology
- •26.6.1 Oral Halitosis (Intraoral Halitosis, Oral Malodor)
- •26.6.1.1 Periodontal Infections
- •26.6.1.2 Tongue Oriented Halitosis
- •26.6.1.3 Peritonsillar Abscess
- •26.7 Paranasal Sinus Diseases
- •26.8 Adenoid Vegetation
- •26.9 Chronic Pharyngitis
- •26.10 Chronic Tonsillitis
- •26.11 Tonsillolith
- •26.12 Non-Oral Halitosis
- •26.13 Gastroesophageal Reflux
- •26.14 Diagnosis
- •26.14.1 Organoleptic Measurement
- •26.14.2 Sulfur Monitoring
- •26.14.2.1 Indirect Methods
- •26.14.2.3 Ammonia Monitoring
- •26.14.2.4 Polymerase Chain Reaction (PCR)
- •26.15 Physical Examination
- •References
- •27.1 Introduction
- •27.2 Epidemiology
- •27.4 Diagnosis
- •27.5.1 Clinical Assessment
- •27.6 Treatment
- •27.6.1 Voice Therapy
- •27.7 Phonosurgery
- •References
- •28.1 Introduction
- •28.2 Epidemiologic Characteristics
- •28.3 Swallowing Physiologic Phases
- •28.3.1.1 Prematurity
- •28.3.1.2 Neuromuscular
- •28.3.1.5 Cardiopulmonary Disease
- •28.4 Symptoms
- •28.5 Clinical Feeding Assessment
- •28.7 Flexible Endoscopic Swallowing Evaluation
- •28.8 Imaging
- •28.9 Endoscopic Assessments
- •28.9.1 High-Resolution Manometry
- •28.10 Medical Management
- •28.11 Surgical Management
- •28.11.1 Ankyloglossia
- •28.11.2 Laryngomalacia
- •28.11.3 Laryngeal Cleft
- •28.12 Conclusions
- •References
- •29.1 Introduction
- •29.2 Reactive Lymph Node Enlargements
- •29.3 Vaccines
- •29.4 Acute Suppurative Lymphadenitis
- •29.6 Granulomatous Lymphadenitis
- •29.6.1 Mycobacterial Infection
- •29.6.2 BCG Vaccine
- •29.6.3 Cat-Scratch Disease
- •29.6.4 Sarcoidosis
- •29.6.5 Kikuchi-Fujimoto Disease
- •29.7 Malignancies
- •29.8 Diagnosis
- •References
- •30.1 Introduction
- •30.2 Upper Airway Cough Syndrome
- •30.3 Chronic Rhinosinusitis
- •30.5 Otogenic Cough
- •30.6 Laryngeal Clefts
- •30.7 Conclusion
- •References
- •31.1 Introduction
- •31.5.1 Vocal Cord Disfunction (VCD)
- •31.5.2 Obstructive Sleep Apnea Syndrome (OSAS)
- •31.5.3 Allergic or Non-Allergic Rhinitis
- •31.6 Conclusion
- •References
- •32.1 Introduction
- •32.2.1 Non-massive Hemoptysis
- •32.2.2 Massive Hemoptysis
- •32.4 Diagnostic Evaluation
- •32.4.1 History
- •32.4.1.1 Infection Warning Signs
- •32.4.1.2 Choking
- •32.4.1.3 Exposures
- •32.4.1.4 Underlying Medical Problems
- •32.4.2 Physical Examination
- •32.4.3 Laboratory Evaluation
- •32.4.4 Imaging
- •32.5.1 Respiratory Illness
- •32.5.3 Trauma
- •32.5.4 Hemoptysis Mimics
- •References
- •33.1 Introduction
- •33.6 Conclusion
- •References
- •34: Pediatric Allergic Rhinitis: Otolaryngology Perspective
- •34.1 Introduction
- •34.2 Epidemiology
- •34.2.1 Prevalence
- •34.2.2 Risk factors
- •34.3.1 Classical Pathway
- •34.3.2 Nasal Pathway
- •34.4.2 Physical Examination
- •34.4.3 Diagnostic Tests
- •34.4.4 Nasal Cytology
- •34.4.5 Imaging
- •34.5.1 Adenoid Hypertrophy
- •34.5.2 Nasal Septal Deviation
- •34.5.3 Chronic Rhinosinusitis
- •34.5.4 Turbinate Hypertrophy
- •34.5.5 Nasal Foreign Body
- •34.5.6 Other Clinical Conditions
- •34.6.1 Saline Irrigation (Douching)
- •34.7 Treatment
- •34.7.1 Oral Antihistamines
- •34.7.2 Intranasal Steroids
- •34.7.3 Leukotriene Inhibitors
- •34.7.5 Oral Steroids
- •34.7.6 Intranasal Antihistamines
- •34.7.7 Immunotherapy (Sublingual-Subcutaneous)
- •34.8 Conclusion
- •References
- •35: Allergic Rhinitis: Pediatric Pulmonologist Perspective
- •35.1 Introduction
- •35.2.1 Epidemiological Relationship
- •35.2.4 Immunopathology
- •35.2.7 Non-pharmaceutical Treatment Method
- •35.2.8 Pharmaceutical Medication Policy
- •35.2.9 Immunotherapy Against Allergens
- •35.6 Conclusion
- •References
- •References
- •37.1 Introduction
- •37.2 Adenoid Hypertrophy
- •37.7 Preoperative Evaluation
- •37.8 Contraindications
- •37.9 Complications
- •37.9.1 Bleeding
- •37.9.2 Hypernasality
- •37.9.3 Surgical Traumas
- •37.9.4 Torticollis
- •37.9.5 Otitis Media
- •37.9.6 Psychological Trauma
- •37.9.7 Nasopharyngeal Stenosis
- •37.9.8 Recurrence
- •37.10 Postoperative Care
- •37.11 Surgery
- •37.12.1 Adenoiditis
- •References
- •38.1 Introduction
- •38.2 Anatomy
- •38.2.1 Palatine Tonsils (Faucial Tonsils)
- •38.2.2 Lingual Tonsil
- •38.2.3 Adenoids (Pharyngeal Tonsil)
- •38.2.4 Tubal Tonsils
- •38.5.1 Viral Tonsillitis
- •38.5.2 Bacterial Tonsillitis
- •38.5.3 Candida
- •38.6.1 Suppurative Complications
- •38.6.1.1 Peritonsillar Abscess (Quincy Tonsil)
- •Lemierre’s Syndrome
- •38.6.2 Nonsuppurative Complications
- •38.6.2.1 Acute Rheumatic Fever
- •38.6.2.2 Poststreptococcal Glomerulonephritis
- •38.6.2.3 Scarlet Fever
- •38.6.2.6 Palmoplantar Pustulosis (PPP)
- •38.6.2.7 IgA Nephropathy
- •38.7 Clinical Manifestation
- •38.7.1 Infection
- •38.7.2 Obstruction
- •38.7.3 Neoplasia
- •38.8 Diagnosis
- •38.8.2 Physical Examination
- •38.8.3 Laboratory
- •38.8.4 Imagining
- •38.8.5 Polysomnography
- •38.9 Treatments
- •38.9.1 Medical Treatment
- •38.9.2 Surgery
- •38.9.2.2 Tonsillectomy
- •38.9.3.1 Intraoperative Complications
- •38.9.3.4 Postoperative Long-Term Complications (>weeks)

5 Immunological Defense Mechanisms oftheRespiratory System
73
NF-kB from the cytoplasm to the nucleus and the transcription of chemokines
and proinammatory cytokines (IL)-8, monocyte chemotactic protein-1, lymphocyte chemoattractant factor (IL-16), IL-6, IL-8, and interferon (IFN)-β.
Subsequently, adhesion molecules increase to attract neutrophils and macrophages to the inammatory site.
7. Professional antigen-presenting cells (APC), such as DCs and alveolar mac-
rophages in the lungs, are vital in directing adaptive immune responses to
inammation, which infectious pathogens invade or tolerate after most environmental exposures and commensals [25]. They detect PAMPs through
PRRs and release chemoattractant and inammatory cytokines, including
tumor necrosis factor-alpha (TNF-α), IL-1β, IL-12, and IL-6, into the alveolar space. IL-12 augments NK cell activity microenvironmentally, and large
amounts of IFN-γ secreted by NK cells enhance the antimicrobial function of
the alveolar macrophages [26]. The microorganisms captured by APCs are
subsequently transported to the draining hilar and mediastinal lymph nodes
to commence an adaptive immune response. Dendritic cells and alveolar
macrophages present epitopes of ingested pathogens through endocytosis or
phagocytosis on major histocompatibility complex class I (MHC-I) or
MHC-II protein complex to naïve CD8+ or CD4+ T cells, respectively. The
second set of signals delivered via costimulatory molecules expressed on the
cell surface of activated APCs activates T cells, initiating an adaptive immune
response.
8. ILCs are innate immune cells belonging to the lymphoid lineage but lacking
adaptive antigen-specic receptors [27]. Depending on their ability to synthesize
and release cytokines and their transcription factor prole, ILCs are divided into
three major helper-like subsets, ILC1, ILC2, and ILC3, which are considered the
innate counterparts of T helper 1 (Th1), Th2, and Th17 cells, respectively. ILC1
cells, which include NK cells, secrete IFN-γ and TNF-α, and express the T-box
transcription factor T-bet or eomesodermin (Eomes). ILC2 cells produce IL-4,
IL-5, IL-9, and IL-13in response to IL-25, IL-33, and thymic stromal lymphopoietin and express high levels of the Th2 signature transcription factor GATA-3.
ILC3 cells release IL-17, IL-22, and GM-CSF at mucosal sites, functioning as
early orchestrators of lung tissue remodeling and brogenesis. Although representing a small portion of the pulmonary immune cells, ILCs play a signicant
role in early protective antimicrobial responses and facilitate the acquisition of
adaptive immunity. They also play pathogenic roles in inammation, allergy,
autoimmunity, and tissue brosis [28].
9. Neutrophils are recruited rapidly to the site of inammation following stimula-
tion by chemotactic factors such as chemokines (CXCL1–8, CXCL-12, CCL2,
and CCL17), lipid mediators (eicosanoids/leukotrienes), C5a, and interleukins
(i.e., IL-8) released from the damaged lung tissues [29]. They localize mainly in
the bronchoalveolar space, engaging in short-term host–pathogen interactions.
Activated neutrophils eliminate microorganisms by phagocytosis, oxidative
burst, degranulation, and by means of NETosis (neutrophil extracellular traps
formation) [1, 29].

74
N. E. Karaca et al.
5.2 Adaptive Immunity
Adaptive immunity involves a tightly regulated interplay between antigen- presenting
cells and the effectors, T and B lymphocytes, which facilitate pathogen-specic
immunologic effector pathways, immunologic memory generation, and regulation
of host immune homeostasis. Cell-mediated immunity is controlled by T cells, and
humoral immunity is controlled by antibody-producing B cells. Highly mobile lymphocytes trafc to secondary lymphoid organs after developing in the primary lymphoid organs (thymus and bone marrow) and serve to capture circulating antigens
from lymph. T cells are primed in the lymphoid areas, often inuenced by innate
immune system signals provided by APCs migrating to the secondary lymphoid
organs. Naive lymphocytes undergo a stepwise process of activation, proliferation,
clonal expansion, and differentiation to become effector cells that can migrate to the
lung and mediate antimicrobial immune responses [30].
The activation of T helper cells by APC causes them to differentiate into different
subtypes with specic functions mediated by cytokine secretion and cell-to-cell
contact. T helper 1 cells secrete cytokines such as IFN-γ, IL-6, and IL-12 and play
a crucial role in cellular response formation [15]. Th2 cells help humoral responses
by providing a second signal to B cells, mostly through IL-4 secretion and CD40/
CD40L interaction. During the rst encounter with an antigen (pathogen), longlived memory T and B cells are established. In subsequent encounters with the same
pathogen, the memory cells are quickly activated to yield a more rapid and robust
protective response. The activated B cells secrete antibodies circulating in the body
and coat the microbes, targeting them for efcient phagocytosis. T follicular helper
cells (Tfh) control the critical interactions in the germinal centers essential for the
maturation of memory B cells and long-lived high-afnity antibody-producing
plasma cells [31]. Another subset of CD4+ T cells differentiates into a pool of memory T helper cells. Activated CD8+ cytotoxic T lymphocytes (CTL) cause apoptosis
of the infected host cells. Some CTLs differentiate into memory cytotoxic T cells,
which have the role of fast restoration of the CTL response with secondary antigen
contacts. A similar destruction mechanism occurs when NK cells interact with the
virally infected cell [31]. They contain granules with IFN-γ and TNF-α in their
cytoplasm. NK cells form pores in the membranes of target cells by perforin.
Granzymes pass through the pores, and together with cytokines, they initiate apoptosis, resulting in the death of infected cells.
After the control of infection, clones from the antigen induces the infection to
circulate, creating lymphocytes that are specic to the circulating antigen. Initially,
these lymphocytes are observed in small populations; however, they can act fast
upon the recolonization of the known antigen, giving the immune system the time
to produce more specic lymphocytes.
Lymphocytes can be found either singly or in clusters in the airway lamina propria
and the submucosa [3, 15]. Effector and memory CD4+ and CD8+ T cells and B cells
are present in the airway mucosa (in the intraepithelial and within the underlying
lamina propria). They may play a role in the constitution of BALT, which has a signicant role in local immunological homeostasis in the respiratory tract. Most

5 Immunological Defense Mechanisms oftheRespiratory System
75
intraepithelial T cells express CD8+, whereas CD4+ T cells are more frequently found
in the lamina propria. B cells contribute to local antigen presentation in the lymph
nodes that drain the lungs. Some B cells differentiate into plasma cells. Plasma cells
located in the lamina propia mainly produce IgA but also IgM to clear inhaled pathogens [32, 33]. IgG subclasses are also present in the alveoli and airway secretions.
The lungs are a major site of entry of innocuous inhaled antigens and presumably
by commensal microorganisms into the body. The absolute requirement of the pulmonary immune system is to limit the infectious and inammatory consequences of
inhaled agents while maintaining tolerance to harmless aeroallergens. The immune
response in the lung must be tightly regulated such that pathogens are cleared.
Furthermore, immunopathology due to chronic or excessive inammation is
avoided. Critical antimicrobial monitoring and downregulation of the activated
immune response are vital to protect the lung from inammatory damage. The
immune homeostasis and tolerance in the lung are maintained by a complex network of cells and molecules interacting with lung stromal cells, such as regulatory
T cells (Tregs), resident interstitial lung macrophages, plasmacytoid dendritic cells,
γδT cells, cytokines IL-10, and TGF-β [33–35]. The coordinated and close interplay
between resident (airway epithelial cells) and inltrating immune cells is important
to establish the protective respiratory innate and adaptive immune responses.
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N. E. Karaca et al.

Innate andAdaptive Immunity
oftheRespiratory System
EsraHazar, MehmetAliKaraselek, andSevgiKeles
6.1 Introduction
The respiratory tract (RT) is a complex system that provides gas exchange and oxygenation of the blood, while at the same time forming a physical and immunological
barrier between the external environment and tissues. Hereby, the respiratory tracts
are constantly exposed to inhaled agents including allergens, pollutants, commensal
or pathogenic microorganisms, and respiratory pathogens [1]. The RT compromises
the upper (URT) and lower respiratory tracts (LRT), and drains the localized lymphoid tissue including cervical and mediastinal lymph nodes to start a localized
immune response against antigens. The tract is covered with a barrier that is composed of a mucus layer, cilia, and airway epithelial cells. The rst line of defense
starts in URT or LRT by interaction between environmental agents and this barrier
in the respiratory tract. This barrier is supported by a complex network of immune
systems which is composed of innate and adaptive immune systems. These systems
recognize and react to a wide variety of stimuli. They also eliminate unwanted
pathogens to keep the tract free from infections. This system also regulates maximizing pathogen clearance while minimizing excessive inammation and tissue
injury. Maintaining balance in the respiratory tract during injury or infection is crucial to host survival [2]. The distribution of these protective mechanisms contributes
to the pathogenesis of many pulmonary diseases. Many diseases, such as asthma,
allergies, and acute or chronic lung diseases, result from dysregulated responses in
the airways. In addition, numerous infectious agents, including viral, bacterial,
6
E. Hazar
Pediatric Allergy and Immunology Unit, Faculty of Medicine, Alanya Alaaddin Keykubat
University, Antalya, Turkey
M. A. Karaselek · S. Keles (*)
Pediatric Allergy and Immunology Unit, Faculty of Medicine, Necmettin Erbakan University,
Konya, Turkey
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_6
77

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E. Hazar et al.
fungal, and protozoan, target airway cells for replication, then cause direct damage
to barrier sites by triggering inammation-related tissue damage.
The respiratory immune system is composed of innate and adaptive immune
systems. Less-virulent pathogens are generally obliterated by the primary defense
like mucociliary clearance and alveolar macrophage, which is a part of innate
immunity in the tract. Contrary, virulent microorganisms and most of the inhaled
antigens/pathogens need to be eliminated by the inammatory process initiated by
the innate immune system. In the early phase of infection with a respiratory pathogen, there is a balance between pathogen clearance and immune response which is
closely controlled by the epithelial immune cell axis. Dysregulation in this response
can cause serious tissue damage. In the late stages of infection, a balance must be
established between inammation and tissue repair to recover proper lung function.
On the other hand, dysregulated airway response to pathogens by innate and adaptive immune systems results in hyperinammatory syndromes, site destruction in
the respiratory tract leading to a sequela such as lung brosis. As a consequence,
innate and adaptive pulmonary immune responses are strictly regulated to maintain
this homeostasis following injury and infection [1]. Hence, knowing the role of
adaptive and innate immune responses in the respiratory tract is important to understanding the pathophysiology and improving the management of respiratory diseases. Here, we have summarized various aspects of immune hemostasis which is
regulated by innate and adaptive immune responses in the respiratory tract.
6.2 Innate Immunity
The innate immune system is the rst line of defense against inhaled materials, and
nonspecically identies the microorganisms by recognition of their common microbial motifs. Thus, it provides a nonspecic response against antigens. Innate immunity is contributed by epithelial cells, dendritic cells, macrophages, neutrophils, innate
lymphoid cells, and monocytes, which respond rapidly to inhaled materials. Activation
of these innate immunity cells induces the production of anti-microbial peptides, chemokines, and cytokines [2]. The intercellular communication between the airway and
the immune cells is facilitated by complement factors, lipid mediators, chemo-attractants, and chemokines. The biological function of chemokines is relayed by different
cytokines, including several interleukins and thymic stromal lymphopoietin (TSLP).
These substances, secreted by local airway cells, generate customized immunological
responses [2, 3]. Important components of theinnate immunity system in the respiratory tract are summarized in the following part of the chapter and in Fig.6.1 [1].
6.2.1 Mucosal Immunity intheRespiratory System
The epithelium is the primary defense line against airborne harmful microorganisms. It captures particles in the air and removes them from the airways. The primary function of this epithelia is to be a physical boundary between the airways and

a bc
6 Innate andAdaptive Immunity oftheRespiratory System
79
Fig. 6.1 Components and cells of innate immunity in the respiratory tract showing at the mucosal barrier (a), activation of antigen-presenting cells by antigens
(b), and additional cells in the lower respiratory system (c)

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E. Hazar et al.
vascular structures. The epithelium accomplishes this by creating tight junctions
that include occludins, claudins, and adherens. Damage to tight junctions is an
important cause of epithelial barrier dysfunction during inammation of the lung.
The epithelial integrity is critical to avoid the colonization and dissemination of
microorganisms, as well as to prevent uid accumulation in the lung [4]. The tight
junction formation can be modied with viruses that target the epithelium. Inuenza
disrupts claudin-4 [5] and respiratory syncytial virus (RSV) [6] and reduces the
expression of claudin-1 and occludins. Some bacterial infections, e.g., lung infection due to Pseudomonas aeruginosa, may cause edema secondary depletion of
zonula occludins-1 proteins [7].
The cartilaginous airway epithelium is constituted of glands, ciliated cells, and
goblet cells. Noncartilaginous airways have no glands or goblet cells, but have an
increasing number of columnar epithelial cells [8]. An important feature of the pulmonary mucosa is the thin uid layer called mucus that covers the airway lumen.
The mucus that is produced by the goblet cells is composed of mucin proteins,
complements, cytokines, secretory IgA, antimicrobial peptides (AMP), and commensal bacteria. Mucins in mucus are extra-cellular proteins that are secreted by
goblet cells, club cells, and pseudostratied columnar ciliated cells of the respiratory epithelia. These proteins play an important role in viral transmission, which can
capture and block virus entry in the affected host. The most prevalent mucins in the
respiratory system are MUC5AC and MUC5B, which are signicant in the protective barrier task [1, 9].
During the acute inammatory phase, unique molecular signatures referred as
pathogen-associated molecular patterns (PAMPs), found in immunogenic vaccines,
bacteria, fungi, viruses, and protozoa, are detected by pattern recognition receptors
(PRRs) secreted by immune cells of epithelia. PRRs such as Nod-like receptors
(NLRs), Toll-like receptors (TLRs), and retinoic acid inducible gene I- (RIG-I-)like receptors (RLRs) are players of innate immunity and apoptosis. Therefore,
PR-intermediated signal paths have an essential task in inammatory responses and
the stability of tissue homeostasis. Respiratory epithelia and cells of innate immunity secrete TLR1, TLR2, TLR3, TLR4, TLR5, TLR6, TLR7, TLR8, TLR9, and
TLR10, which recognized distinct antigens. While TLR1, TLR2, TLR4, TLR5,
TLR6, and TLR10 are located at the cell surface, TLR3, TLR7, TLR8, and TLR9
are locatede in intracellular vesicules (endoplasmic reticulum, endosome, lysosome, and endolysosome). Plasma membrane-associated TLRs and endosome
membrane-associated TLRs are primarily responsible for recognizing bacteria in
the lung, while TLR3, TLR7, and TLR8 detect virus nucleic acids in lung infections
[10]. Studies have shown that dsRNA recognized by TLR3 (such as in the inuenza
virus) was the most potent activator of epithelial cells in the lung, and stimulates a
potent cytokine and chemokine response. TLR2 and TLR5 promote an increased
response of the airway epithelium, leading to a more efcient response to bacteria
and allergens. TLR4 is capable of recognizing Gram-negative bacteria and stimulating upregulation of TLR3in alveolar macrophages [4].
Another subtype of PRRs is the nucleotide-binding oligomerization domain
(NOD)-like receptors (NLRs). NLRs are secreted in the cytoplasm and nucleus.

6 Innate andAdaptive Immunity oftheRespiratory System
81
There are more than 20 receptors in the NLR family. There are four kinds of effector
domains with specic functional features that allow the NLR to be divided into ve
different subfamilies: NLRA, NLRB, NLRC, NLRP, and NLRX.The human NLRC
is a subfamily of NLR composed of ve members (NLRC1–5). NLRC1 and
NLRC2, also called NOD1 and NOD2, are the two major components of the NLRC
subfamily [10].
NOD1 is widely expressed in respiratory epithelia, endothelia, smooth muscles,
and leukocytes. However, NOD2 expression is limited in myeloid cells, which
include dendritic cells, macrophages, and human bronchial epithelial cells.
Following ligand recognition, NLRC members induce the activation of distinct signaling paths through CARD–CARD interactions with several types of proteins.
While NOD1 and NOD2 both recognize different ligands via leucine-rich repeat
(LRR) domains, they act through the same protein called receptor-interacting serine/threonine-protein kinase 2 (RIPK2). RIPK2-mediated activation gives rise to
the regulation of several pathways involved in different cellular responses, including inammatory responses through nuclear factor kappa-light-chain-enhancer of
activated B cells (NF-κB) and mitogen-activated protein kinase (MAPK) activation.
NOD1 or NOD2 codependent induction of these paths can interfere with other
PRRs, e.g., TLRs [11].
NLRP is the biggest NLR sub-family counting 14 members. At a minimum, ve
of the NLRP elements, including NLRP1, NLRP3, NLRP6, NLRP7, and NLRP12,
can activate the generation of inammasome, and modulate the release of IL1β and
IL18 in response to different damage-associated molecular pattern (DAMP) or
microbe-associated molecular pattern (MAMP). NLRP1 inammasome is the rst
identied intracellular molecule capable of activating pro-caspase 1. NLRP3 is the
well-characterized member of the NLRP sub-family, and the most studied inammasome. The initial signal by DAMP or MAMP inammatory stimulus induces
NF-κB-mediated NLRP3 expression. Following the rst signal, the NLRP3 stimulation is driven by a secondary signal, which is induced by a broad range of stimuli,
in particular bacterially sourced molecules such as LPS, endogenous DAMP such as
ATP, viral RNA, hyphae of fungi, or exposed to other environmentally irritating
substances. NLRP1 is expressed in the digestive and respiratory epithelial immune
cells and brain. NLRP3 is expressed in various immune cells (macrophages, dendritic cells, neutrophils, and T and B lymphocytes). In addition, NLRP3 is found in
respiratory and intestinal epithelium [10, 11].
Antimicrobial peptides (AMPs) are widely expressed in the lung, serving as the
initial defensive line for protection against infection. Defensins (alpha and beta),
surfactant proteins, RegIIIγ, and LL-37 are some AMPs in the respiratory system.
Defensins are primarily expressed in neutrophils and epithelial cells. Alpha defensins have a potent anti-viral impact by targeting viral particles and disrupting their
capability to invade cells. Beta-defensins also act as chemokines, indirectly enhancing immunity to infections. LL-37 secreted by myeloid and epithelial cells is a
member of the cathelicidin family. It has antimicrobial properties by inhibiting LPS
and disrupting the bacterial membrane. It also promotes the expression of IL-8 and
activation of the epithelial growth factor receptor (EGFR) in epithelial cells [4].

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One other signicant anti-microbial peptide is regenerating islet-derived 3 γ
(RegIIIγ), which is particularly targeting Gram-positive bacteria. It is vital for the
elimination of methicillin-resistant Staphylococcus aureus (MRSA) associated
pneumonia. STAT3 regulates the expression of RegIIIγ, which is highly expressed
in the lung epithelium during MRSA infection [12].
Surfactant proteins A (SP-A) and D (SP-D) are known to be members of the collectin AMP family. The binding of collectins to pathogens leads to opsonization and
subsequent phagocytosis. SP-D has a potent anti-infective activity against inuenza
and is proposed as a promising treatment to boost mucosal immunity during inuenza epidemics [13]. SP-C has been demonstrated to have immunomodulatory
effects in lung repair through JAK/STAT activation after acute respiratory distress
syndrome (ARDS) [14].
The complement system is composed of plasma proteins that serve as immune
system effectors by inducing phagocytosis, increasing active inammatory mediators, and targeting the pathogen’s membrane [4]. Overactivation of complement
may lead to damaged tissues. For example, H5N1 avian inuenza has been reported
to cause acute lung injury and ARDS by leading the hyperactivation of complement.
In this model, the inhibition of complement activation helps to reduce injury in the
lung [15].
6.2.1.1 Cells ofInnate Immunity
The major cells of the innate immune system are epithelial cells, neutrophils, dendritic cells, macrophages, monocytes, and innate lymphoid cells. Alveolar epithelial
cells (AECs) are one of the important cells of innate immunity in the lung. Both
AEC I and AEC II coordinate different immune pathways to provide homeostasis in
the lung. AEC I covers almost 99% of the lung surface area. Besides acting as a
physical barrier, both AEC I and AEC II have a crucial role in the lung’s immune
response. However, AEC II is more immunologically active. These cells produce
several immune factors such as cytokines and chemokines that are responsible for
immune cell activation and differentiation. They act as antigen-presenting cells for
specic T cells [2].
Macrophages are the other important cells of the innate immunity to response to
infections. They express numerous surfaces, vesicular and cytosolic PRR to detect
signals, and start appropriate immune responses. Following its activation, these
cells phagocytize, directly kill infectious agents, then recruit other innate immune
cells by releasing numerous cytokines and chemokines. After stimulation, in circulation, monocytes are differentiated into dendritic cells (DCs) or macrophages, and
initiate innate immune response in the lung. On the other hand, tissue-resident macrophages are present in the lung. These macrophages are the initial responders and
have signicant tasks in homeostasis, immunomodulation, and tissue repair.
Macrophages in the lungs are classied into two groups: alveolar macrophages
(AMs) and interstitial macrophages (IMs). AMs are supposed to have a central role
in a clearance of pathogens, while IMs act as a major immunomodulator of adaptive
immunity because of their elevated expression of MHCII [4]. Both macrophages
produce robust responses to a wide range of stimuli. AMs promote viral clearance
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