Evidenz basierte Indikationen der Tonsillektomie

Zusammenfassung

Hintergrund: Die erste wissenschaftlich hochwertige Studie zur Indikationsstellung der Tonsillektomie wurde von Jack L. Paradise geleitet und 1984 (TE) publiziert. Ziel dieser systematischen Literaturrecherche war es, anhand einer standardisierten Suchstrategie Publikationen zusammenzustellen, die sich nach 1984 mit den Operationsindikationen der TE auseinandersetzten.

Methoden: berücksichtigt wurden ausschließlich systematische Reviews, Metaanalysen, Leitlinien sowie Publikationen zu Evidenz-basierten Operationsindikationen der TE. Zunächst wurde in der Medline-Datenbank mit dem Suchwort „tonsillectomy“ in Kombination mit den Filtern „Systematic Reviews“ sowie „Meta-Analysis“, „English“, „German“ und „from 1984/01/01 to 2015/05/31“ recherchiert. In der „Cochrane Database of Systematic Reviews“, im Register des „National Guideline Clearinghouse“, bei dem „Guidelines International Network“ und „BMJ Clinical Evidence“ wurde ausschließlich das Suchwort „tonsillectomy“ verwendet. Schließlich wurde bei „Trip Database“ eine Recherche mit den Suchwörtern „tonsillectomy“ und „indication“ sowie den Filtern „from: 1984 to: 2015“ entweder mit „systematic review“ oder „metaanalysis“ oder „meta-analysis“ vorgenommen.

Ergebnisse: Von 237 Treffern bei der Literaturrecherche entsprachen 57 Artikel den Suchkriterien und konnten den Themengebieten Peritonsillarabszess (3), Psoriasis (3), Leitlinien (5), Paukenerguss (5), Evidenz-basierte Indikationen (5), PFAPA-Syndrom (6), Nierenerkrankungen (7), Schlaf-bezogene Atmungsstörungen (11) und Tonsillitis/Pharyngitis (12) zugeordnet werden.

Schlussfolgerungen: Die Übersichtsarbeiten der letzten 31 Jahre zu Indikationen der TE setzten sich mit 7 Krankheitsbildern auseinander: 1) Im Fall des Paukenergusses darf davon ausgegangen werden, dass die TE nicht gerechtfertigt ist und auch kein weiterer Forschungsbedarf dazu besteht. 2) beim PFAPA-Syndrom erscheinen die Operationsrisiken der TE angesichts der möglichen Alternativtherapie in Form von Steroidgaben sowie der wahrscheinlichen Spontanheilung kaum vertretbar. 3) Die Abszess-TE zur Behandlung eines Peritonsillarabszesses ist nur noch in therapierefraktären Fällen, eingetretenen Komplikationen, anamnestisch häufigen Tonsillitiden sowie ausgesuchten Einzelfällen vorbehalten, nicht aber als Routineverfahren. Für die Intervall-TE als Routineverfahren gibt es keine wissenschaftliche Grundlage. 4) Die TE in Form der Adenotonsillektomie zur Therapie von kindlichen Schlaf-bezogenen Atmungsstörungen wegen einer adenotonsillären Hyperplasie gilt als unstrittige Operationsindikation. Der Umgang mit Komorbiditäten wie Adipositas erfordert weitere klinische Forschung, da hierdurch der Operationserfolg erheblich reduziert wird. Der initial gleichwertige Effekt der weniger invasiven Tonsillotomie geht tendenziell im Langzeitverlauf verloren, hier muss an validen Selektionskriterien gearbeitet werden. 5) Die Hinweise auf einen positiven Effekt der TE auf die Psoriasis guttata bei Kindern sowie der therapierefraktären Psoriasis vulgaris bei Erwachsenen lassen sich nicht verneinen, hier besteht aber weiterhin klinisch-wissenschaftlicher Forschungsbedarf. 6) Inwieweit der TE eine Bedeutung im Behandlungskonzept der Ig-A Nephropathie zukommt, muss ebenfalls durch weitere Studien geklärt werden. 7) Sofern die TE auf eine Beseitigung der Gruppe A beta-hämolysierende Streptokokken abzielt, steht sie in Konkurrenz zur Antibiotikumtherapie, aber auch einer nicht zu vernachlässigenden Spontanheilungsrate. Ob die TE bei schweren Verlaufsformen von Tonsillitiden, gemessen an der Zahl von Halsschmerz-Episoden, der konservativen Therapie nachhaltig überlegen ist, muss die dringend angezeigte klinisch-wissenschaftliche Forschung noch nachweisen. Hierbei muss auch die Frage beantwortet werden, inwieweit Unterschiede zwischen Kindern, Jugendlichen und Erwachsenen bestehen.

Abstract

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of Evidence-based Medicine.

Material and Methods: A systematic Medline research was performed using the key word „tonsillectomy“ in combination with different filters such as „systematic reviews“, „meta-analysis“, „English“, „German“ and „from 1984/01/01 to 2015/05/31“. Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the „Trip Database“ were researched for „tonsillectomy“ and „indication“ and „from: 1984 to: 2015“ in combination with either „systematic review“ or „meta-analysis“ or „metaanalysis.

Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA-Syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively.

Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA-syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Schlüsselwörter

Tonsillektomie - Tonsillotomie - Tonsillitis - Schlaf-bezogene Atmungsstörungen - IgA-Nephropathie - Psoriasis - PFAPA-Syndrom - Peritonsillarabszess - Komplikationen - Nachblutung

Key words

tonsillectomy - tonsillotomy - tonsillitis - sleep-related breathing disorders - IG-A nephropathy - psoriasis - peritonsillar abscesscomplications - post-tonsillectomy hemorrhage

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