Erkrankungen der Gaumenmandeln im Kindesalter

Zusammenfassung

Die Operation an den Gaumenmandeln ist im Kindesalter eine der häufigsten, und oftmals ist es der erste chirurgische Eingriff bei einem kleinen Patienten. Seit der medienwirksamen Häufung an Todesfällen von Kindern nach Tonsillektomie in Österreich 2006 kommt es langsam zu einem Paradigmenwechsel in Deutschland. Da jedoch klare Leitlinien fehlen, werden Eingriffe an den Tonsillen je nach Landkreis und Vorlieben sehr inhomogen gehandhabt. In einigen Kreisen werden 8-mal so vielen Kindern die Gaumenmandeln entfernt wie in anderen. Kinder unter 6 Jahren sollten nur noch bei andauernden bakteriellen Mandelentzündungen komplett tonsillektomiert werden. Die Teilentfernung der hyperplastischen Mandeln, die Tonsillotomie, ist wesentlich risikoärmer und der Tonsillektomie vorzuziehen. Die Blutungsgefahr und die postoperativen Schmerzen sind bei der Tonsillotomie deutlich geringer als bei der Tonsillektomie. Die Tonsillotomie kann mit dem Laser, Radiofrequenzgerät, Shaver, Coblation, bipolarer Schere oder monopolarer Nadel durchgeführt werden. Entscheidend ist, dass die Krypten offen bleiben und lymphatisch aktives Gewebe in der Fossa tonsillaris zurück bleibt. Die Indikation zur Tonsillektomie besteht weiterhin bei rezidivierenden bakteriellen Infekten, Antibiotikaallergie, PFAPA Syndrom (periodisches Fieber, Apthen, Pharyngitis, Adenitis) und Peritonsillarabszess (einseitig). Bei den rezidivierenden Tonsillitiden kommt es auf die Schwere und die Häufigkeit an. Bei Kindern bis zum Alter von 16 Jahren sollte man sich an die Paradise Kriterien halten: Eine Indikation zur klassischen, kompletten Tonsillektomie besteht bei 5 oder mehr Tonsillitiden in mindestens 2 aufeinander folgenden Jahren oder bei 7 oder mehr Tonsillitiden innerhalb eines Jahres. Die Diagnose Tonsillitis kann klinisch gestellt werden. Sie besteht bei Schmerzen, tonsillärem Exsudat und Fieber>38,3°C. Wandernder Schmerz, niedrigeres Fieber und Husten lassen eher an eine Viruspharyngitis denken. Im Zweifel sollte ein Abstrich oder Antigentest angelegt werden. Beim Abstrich oder Antigen-Schnelltest muss aber berücksichtigt werden, dass Viren, Bakterien und Pilze zur transienten Mundflora gehören und 10% aller Kinder klinisch inapparente, nicht behandlungsbedürftige Dauerausscheider von Streptokokken sind. Screeningtests mittels Antistreptolysintiter, Abstrichen oder Schnelltests (wie von manchen Kindertagesstätten gefordert) sind daher sinnlos und rechtfertigen keine Antibiotikatherapie.

Die akute, bakterielle Tonsillitis sollte mit nicht steroidalen Antirheumatika (z. B. Ibuprofensaft), Betalactamantibiotika (z. b. Penicillin oder Cefuroxim) und bei Kindern und Jugendlichen auch oralem Steroid (z. B. Dexamethason) behandelt werden. Hinsichtlich der Verkürzung des Krankheitsverlaufes und der Reduktion der Symptome ist die Kurzzeittherapie mit Azithromycin (20mg/kg KG) für 3 Tage oder Clarithromycin und einem Cephalosporin für 5 Tage der Langzeit Penicillintherapie ebenbürtig. Auch das frühzeitige Absetzen der Penicilline nach 5 Tagen zeigte keine Nachteile im Krankheitsverlauf, der Rezidivrate oder der Resistenzbildung. Aber nur die empfohlene 10 Tage Antibiotikatherapie senkt die Inzidenz des rheumatischen Fiebers (derzeit 0,5 Fälle pro 100 000 Kinder in Europa) und der Glomerulonephritis signifikant.

Hauptproblem bei der Tonsillektomie ist, neben dem Schmerz, die gefürchtete Spätnachblutung. Diese kann bis zum kompletten Abheilen der Wunde (i. d. R. nach drei Wochen) auftreten und lebensbedrohlich sein. Größere Massenblutungen kündigen sich oft durch kleinere, spontan sistierende Blutungen an. Daher muss jede Nachblutung ernst genommen und der betroffene Patient stationär aufgenommen werden. Die Patienten und die Eltern sind über das korrekte Vorgehen bei Nachblutung idealerweise vor der Operation, aber spätestens bei Entlassung, schriftlich zu informieren. Das Informationsblatt sollte Adressen, Notruftelefonnummern und Ansprechpartner enthalten. Schwere oder letale Verläufe entstehen meist durch falsches Management der Nachblutung. Eine besondere Lebensgefährdung besteht bei Kleinkindern, die ein geringes Blutvolumen haben und relativ viel Blut unbemerkt schlucken können, bzw. aspirieren. Für den Notarzt stellt die Intubation einer massiven Nachblutung nach Tonsillektomie eine extreme Herausforderung dar, welche oft nur mit einem geeigneten starren Tonsillensauger bewerkstelligt werden kann.

Alle Operationstechniken haben ein Risiko der Nachblutung und selbst der erfahrenste Operateur ist nicht davor gefeit. Jedoch zeigte die „Kalte Dissektion“ mit Ligatur oder Umstechungen die geringsten Nachblutungsraten. Nach Laser-, Coblations-, mono- oder bipolaren Techniken kommt es signifikant häufiger zu schweren Nachblutungen.

Kinder mit Gerinnungsstörungen bluten häufiger nach und können präoperativ unentdeckt bleiben. Eine standardisierte Blutungsanamnese (17 Punkte Checkliste), wie von den Fachgesellschaften für Pädiatrie, Anästhesie und HNO empfohlen, ist sensitiver und einfacher als das Screening mittels Gerinnungsparametern. In der Realität zeigt sich jedoch, dass in Deutschland sehr viele der operativ-tätigen HNO Ärzte weiterhin harte Laborwerte wie INR und PTT bevorzugen, obwohl diese den häufigen Von-Willebrand-Faktormangel nicht detektieren ­können.

Abstract

Tonsillitis and Sore Throat in Childhood

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcome after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy slowly change in Germany since that. However, there exist no national guidelines and the frequency of tonsil surgery varies in the country. In some districts eight times more children were tonsillectomized than in others.

A tonsillectomy in children under 6 years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i. e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (= tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (perio­dic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of the healthy children bear even strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens).

The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for 3 to 5 days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistence between the short-term penicilline therapy to the standard 10 days therapy, as well. On the other hand, only the 10 days antibiotic therapy has proofen to be effective in the prevention of rheumatic fever and glomerulonephritic desaeses. The incidence of rheumatic heart desease is currently 0.5 per 100.000 children in school age. The main morbidity after tonsillectomy is pain and the late hemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completly healed, which is normally after 3 weeks. Life-threatening hemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every hemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behavior in case of hemorrhage with a written consent before the surgery.

The handout should contain important adresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of hemorrhage. Especially in small children hemorrhage can be life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive hemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate unflexible suction tubes.

All different surgical techniques have the risk of hemorrhage and even the best surgeon will experience a postoperative hemorrhage. The lowest risk of hemorrhage is after cold dissection with ligature or suturing. All „hot“ techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late hemorrhage.

Children with a heredetary coagulopathy have a higher risk of hemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised ques­tionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-points-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these test are inappropiate and incapable of detecting the von Willebrand desease, which is the most often coagulopathy in Europe.

The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

Schlüsselwörter

Tonsillitis - Tonsillektomie - Tonsillotomie - intrakapsulär - extrakapsulär - Antibiotikatherapie

Key words

tonsillitis - tonsillectomy - intracapsular - extracapsular - antibiotics

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