[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 streptococcus 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 resistance 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 prooven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease 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 completely 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 hereditary 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 disease, 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.