Enlarged adenotonsillar tissue (AT) is a major determinant of obstructive sleep apnea (OSA) severity in children; however, mechanisms of AT proliferation are poorly understood. We hypothesized that early exposure to respiratory syncytial virus (RSV) may modify AT proliferation through up-regulation of nerve growth factor (NGF)-neurokinin 1 (NK1) receptor dependent pathways. AT harvested from 34 children with OSA and 25 children with recurrent tonsillitis (RI) were examined for mRNA expression of multiple growth factors and their receptors. In addition, NK1 receptor expression and location, and substance P tissue concentrations were compared in AT from OSA and RI children. NGF mRNA and its high-affinity tyrosine kinase receptor (trkA) expression were selectively increased in OSA (p Ͻ 0.001). NK1 receptor mRNA and protein expression were also enhanced in OSA (p Ͻ 0.01), and substance P concentrations in OSA patients were higher than in RI (p Ͻ 0.0001). AT from OSA children exhibit distinct differences in the expression of NGF and trkA receptors, NK1 receptors, and substance P. The homology between these changes and those observed in the lower airways following RSV infection suggests that RSV may have induced neuro-immunomodulatory changes within AT, predisposing them to increased proliferation, and ultimately contribute to emergence of OSA. O bstructive sleep apnea syndrome (OSA) is a common and highly prevalent disorder in the pediatric age range, affecting 2-3% of all children (1). Adenotonsillar hypertrophy is by far the major pathophysiological contributor to OSA in children (2,3), and adenotonsillectomy (T&A) currently remains the first line of treatment for children with OSA (4). If left untreated, OSA can result in serious morbid consequences that affect neurocognitive, behavioral and cardiovascular systems (5-9). However, the mechanisms underlying the regulation of benign follicular lymphoid proliferation and hyperplasia are so far extremely poorly understood, such that prediction of which children will develop adenotonsillar hypertrophy is impossible at this stage. It has now been recognized by several epidemiologic studies that factors such as environmental smoking, allergies, and intercurrent respiratory infections are all associated with either transient or persistent hypertrophy of lymphadenoid tissue in the upper airways of snoring children (10 -12). Interestingly, all of these risk factors involve the generation of an inflammatory response, suggesting that the latter may promote the onset and maintenance of proliferative signals to lymphadenoid tissues.Bronchial-associated lymphoid tissue in the lungs of RSVinfected rats express high levels of the neurokinin 1 (NK1) receptor for substance P that is released from subepithelial sensory nerve fibers, a part of the nonadrenergic noncholinergic system (13,14). Furthermore, nerve growth factor (NGF), a major controller of sensorineural development and immuno-inflammatory responses, and its tyrosine kinase A receptor (trkA) are both overexpressed...