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„Resttonsillen“ sind gelegentlich Gegenstand juristischer Auseinandersetzung nach Tonsillektomie, aber obligat nach Tonsillotomie vorhanden. Bei klinisch relevanter Symptomatik kann in beiden Fallen eine sekundare Tonsillektomie (STE) notwendig werden. Ziel dieser retrospektiven Longitudinalstudie war es, die Pravalenz der STE in Deutschland anhand einer Auswertung des Statistischen Bundesamts zu erfassen. Die STE wurde uber den OPS-Code (Operationen- und Prozedurenschlussel) 5‑281.4 identifiziert und die Pravalenz nach Jahrgang, Alter und Geschlecht stratifiziert. Es wurde eine lineare Regressionsanalyse uber die Zeit durchgefuhrt. Zusatzlich wurde die Anzahl der stationar durchgefuhrten Tonsillektomien und Tonsillotomien durch die OPS-Codes 5‑281.5, 5‑281.0 und 5.282.0 identifiziert. Zwischen 2005 und 2018 wurden in Deutschland 11.018 Patienten sekundar tonsillektomiert. Es zeigt sich ein signifikanter Ruckgang der Gesamtzahlen an STE uber die Zeit (p

BACKGROUND Tonsillectomy is a reasonable indication in the management of sore throat not responding to antibiotic treatment. This longitudinal patient-level study was conducted to estimate the impact of the German guideline for the management of tonsillitis which was published in 2015. METHODS Data of inpatient and outpatient healthcare were retrieved from a database provided by one of the largest German health insurance companies (i.e., Allgemeine Ortskrankenkassen). Procedures for the management of chronic tonsillitis (code: J35.0) between 2012 and 2018 were identified by operation codes (5-281.0; 5‑282.0). Primary care data concerning sore throat were identified by ICD-10 codes (J02; J03; J35.0) including antibiotic prescribing by associated data of the anatomic-therapeutic-chemical classification. RESULTS A total of 109,895 cases were eligible for analysis. The annual number of procedures had decreased by 50.3% within the study period. The continuous decrease was emphasized after 2015. The strongest decrease was registered in children (

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany. Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years). Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p

Fur die (Adeno‑)Tonsillektomie und Tonsillotomie hat der gemeinsame Bundesausschuss seit 2018 das Zweitmeinungsverfahren verpflichtend eingefuhrt, weil es sich um „mengenanfallige“ Eingriffe handeln soll. Diese Studie zielte darauf ab, die quantitative Entwicklung beider Eingriffsarten in Deutschland darzustellen und zu analysieren. Die uber das statistische Bundesamt zwischen 2005 und 2017 erfassten Eingriffszahlen wurden jahrgangsweise in Bezug auf die Bevolkerung als Eingriffsraten berechnet. Dann wurden die prozentualen Veranderungen der Eingriffsraten im Vergleich zum Vorjahr, jeweils fur die Bundesrepublik, Facharzte, Facharzte der einzelnen Bundeslander, sowie fur die einzelnen Altersgruppen (≤10; ≤20; ≤40; >40 Jahre) kalkuliert. Die Regressionsanalyse belegte einen signifikanten Ruckgang bei der (Adeno‑)Tonsillektomie und eine signifikante Zunahme bei der Tonsillotomie in allen untersuchten Jahren (p

Die Tonsillektomie zahlt zu den haufigen Eingriffen in Deutschland, deren Anzahl durch demografische Veranderungen, das Aufkommen der Tonsillotomie und der Leitlinie zur Tonsillitistherapie beeinflusst sein konnte. Die Zahl der jahrlich in den Bundeslandern ausgefuhrten Tonsillektomien, Adenotonsillektomien und Tonsillotomien sollte erfasst werden. Anhand einer Sonderauswertung durch das Statistische Bundesamt wurde pro Jahrgang und Bundesland die Zahl der stationar versorgten Patienten ohne Beschrankung in Bezug auf Alter oder Geschlecht erfasst, bei denen die genannten Eingriffsarten erfolgt waren. Die Operationsraten wurden in Bezug auf die Einwohnerzahl kalkuliert. Mittels Regressionsanalyse wurden die einzelnen Bundeslander, Jahrgange und Altersgruppen verglichen, mit dem Pearson-Korrelationskoeffizienten erfolgte der Vergleich der Variablen. Zwischen 2005 und 2017 wurden 1.313.449 Operationen ausgefuhrt. Die Gesamtrate (pro 100.000) ging sowohl fur die Tonsillektomie (von 92 auf 43) als auch – noch viel mehr – fur die Adenotonsillektomie (von 51 auf 15) zuruck. Im Gegensatz dazu stieg die Tonsillotomierate von 6 auf 22 an. In der Korrelationsanalyse war dieser Zusammenhang stark positiv (r = 0,986). Der in den Bundeslandern festzustellende Trend zeichnete sich seit langer Zeit und somit unabhangig von der Publikation der Leitlinie zur Tonsillitis ab. Bundesweit hat die Aktivitat auf dem Gebiet der stationaren Tonsillenchirurgie nachgelassen, der Ruckgang der Tonsillektomiehaufigkeit und die Zunahme der Tonsillotomiehaufigkeit waren im Jahresvergleich jeweils signifikant. Signifikante Unterschiede im Vergleich zum bundesdeutschen Trend wurden fur 7 der 16 Bundeslander nachgewiesen.

Tonsillar remnants are occasionally the subject of clinical negligence claims in tonsillectomy patients, but obligatory in every tonsillotomy procedure. In both cases, clinically relevant symptoms can require a secondary tonsillectomy (STE).The purpose of this retrospective longitudinal study was to identify the prevalence of STE in Germany between 2005 and 2018, using a report commissioned by the Federal Office for Statistics.STE was identified using the operation and procedure key (Operationen- und Prozedurenschlüssel, OPS) code 5‑281.4, and the prevalence stratified by year, age, and gender. Linear regression analysis was performed. In addition, the prevalence of tonsillectomy and tonsillotomy was determined by the OPS codes 5‑281.5, 5‑281.0, and 5.282.0.Between 2005 and 2018, 11,018 patients underwent STE in Germany. The total number of STE per year decreased significantly from 1080 in 2005 to 483 in 2018 (p 0.001). The number of inpatient tonsillotomy cases increased between 2007 and 2018 from 4658 to 18,369.The annual number of STE in Germany decreased continually during the observation period. The population-based data used in the study were insufficient to determine whether STE had been performed after tonsillectomy or tonsillotomy. Further patient-level research is thus required.HINTERGRUND: „Resttonsillen“ sind gelegentlich Gegenstand juristischer Auseinandersetzung nach Tonsillektomie, aber obligat nach Tonsillotomie vorhanden. Bei klinisch relevanter Symptomatik kann in beiden Fällen eine sekundäre Tonsillektomie (STE) notwendig werden.Ziel dieser retrospektiven Longitudinalstudie war es, die Prävalenz der STE in Deutschland anhand einer Auswertung des Statistischen Bundesamts zu erfassen.Die STE wurde über den OPS-Code (Operationen- und Prozedurenschlüssel) 5‑281.4 identifiziert und die Prävalenz nach Jahrgang, Alter und Geschlecht stratifiziert. Es wurde eine lineare Regressionsanalyse über die Zeit durchgeführt. Zusätzlich wurde die Anzahl der stationär durchgeführten Tonsillektomien und Tonsillotomien durch die OPS-Codes 5‑281.5, 5‑281.0 und 5.282.0 identifiziert.Zwischen 2005 und 2018 wurden in Deutschland 11.018 Patienten sekundär tonsillektomiert. Es zeigt sich ein signifikanter Rückgang der Gesamtzahlen an STE über die Zeit (p 0,001). Die Gesamtzahl pro Kalenderjahr reduzierte sich kontinuierlich von 1080 im Jahr 2005 auf 483 im Jahr 2018. Die Zahl der stationär ausgeführten Tonsillotomien stieg zwischen 2007 und 2018 von 4658 auf 18.369 Eingriffe an.Innerhalb des Beobachtungszeitraums sank die Zahl der STE kontinuierlich. Anhand des populationsbasierten Datenmaterials konnte nicht geklärt werden, ob der STE eine Tonsillektomie oder Tonsillotomie vorausging. Hierzu sind weitere Studien erforderlich.

Tonsillectomy is a reasonable indication in the management of sore throat not responding to antibiotic treatment. This longitudinal patient-level study was conducted to estimate the impact of the German guideline for the management of tonsillitis which was published in 2015.Data of inpatient and outpatient healthcare were retrieved from a database provided by one of the largest German health insurance companies (i.e., Allgemeine Ortskrankenkassen). Procedures for the management of chronic tonsillitis (code: J35.0) between 2012 and 2018 were identified by operation codes (5-281.0; 5‑282.0). Primary care data concerning sore throat were identified by ICD-10 codes (J02; J03; J35.0) including antibiotic prescribing by associated data of the anatomic-therapeutic-chemical classification.A total of 109,895 cases were eligible for analysis. The annual number of procedures had decreased by 50.3% within the study period. The continuous decrease was emphasized after 2015. The strongest decrease was registered in children (10 years; -65.7%). Every second patients had received conservative treatment at the most in only one preoperative quarter.The impact of the German guideline on the management of sore throat on the annual number of tonsillectomies and common medical practice was limited. Antibiotic treatment appears not to play a major role when tonsillectomy is indicated.HINTERGRUND: Die Tonsillektomie (TE) zielt darauf ab, die Gaumenmandeln als Ursache von rezidivierenden akuten Tonsillitiden zu entfernen, wenn diese konservativen Maßnahmen nicht zugänglich sind. Konsentierte Leitlinienempfehlungen hierzu wurden in Deutschland im Jahr 2015 publiziert. Die vorliegende Studie zielte darauf ab, dem Effekt dieser Leitlinie auf die Indikationsstellung der TE unter Nutzung von individuellen Patientendaten nachzugehen.Anonymisierte Abrechnungsdaten der Allgemeinen Ortskrankenkassen aus stationärer und ambulanter Behandlung sowie Arzneiverordnungsdaten der Jahre 2012–2018 wurden personenbezogen zusammengeführt und ausgewertet. Über die Operationscodierung wurden alle Tonsillektomiefälle erfasst, die wegen einer „chronischen Tonsillitis“ ausgeführt worden waren. Die ambulante Vorbehandlung wegen Halsschmerzepisoden wurde mittels der relevanten ICD-10-Diagnoseschlüssel und die Arzneiverordnungen anhand des anatomisch-therapeutisch-chemischen Systems identifiziert.Zur Auswertung waren 109.895 Krankenhausfälle geeignet, die einen Fallzahlrückgang von 50,3 % innerhalb des Beobachtungszeitraums ergab. Der kontinuierliche Rückgang erhielt einen Akzent nach 2015. Besonders stark waren davon die unter 10-Jährigen betroffen (−65,7 %). Bei etwa der Hälfte aller Tonsillektomierten fanden sich in keinem oder nur einem Quartal ambulante antibiotische Vorbehandlungen.Auf die Fallzahlentwicklung und gängige Praxis bei der Behandlung von Halsschmerzen ließ sich nur ein sehr limitierter Leitlinieneffekt nachweisen. Antibiotikaverordnungen spielen bei der Indikationsstellung der TE als Therapie von Halsschmerzen eine untergeordnete Rolle.

Die Selektivvertrage der Krankenkassen mit den Leistungserbringern sehen eine Fotodokumentation vor, um die Indikationsstellung der Tonsillotomie adaquat rechtfertigen zu konnen. Im Jahr 2017 fuhrte die HNO-Klinik Monchengladbach eine standardisierte Fotodokumentation bei diesem Eingriff ein. Anhand der archivierten Fotodokumente sollte uberpruft werden, ob sich die Abstande der medialen Tonsillenflachen durch das Aufspannen des Tonsillenspatels signifikant verandern. Fotos wurden durch das Operationsmikroskop unmittelbar nach Einsetzen und Offnen des Spatels angefertigt, ohne ihn aufzuspannen (D1), dann nach zusatzlichem Einhangen vor (D2) und nach der Tonsillotomie (D3). Es wurde jeweils ein 10-mm-Ausschnitt eines Einmal-Papierlineals in den Situs gebracht, um die Abstande genau messen zu konnen. Die Fotos wurden aus der digitalen Patientenakte in eine Powerpoint-Datei kopiert, um uber ein eingefugtes, variabel gestaltbares Rechteck die Distanzbestimmungen vorzunehmen. Die Dokumentation von 149 Patienten in einem 6‑Monats-Zeitraum wurde analysiert. Es handelte sich um etwa gleich viele mannliche wie weibliche Patienten, der jungste Patient war 16 Monate, der alteste 48 Jahre alt (Durchschnitt: 6,95; Median: 5 Jahre). Bei allen Patienten fand sich eine signifikante Weitung des Pharynxdurchmessers (p

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany.Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40;40 years).Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures.There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence. To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany. Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient. Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986). The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

Morbidity following tonsil surgery is widely determined by pain, odynophagia, and bleeding. Detailed information about postoperative care in pediatric patients in Germany in the context of otolaryngologic interventions is currently lacking.A questionnaire including eight questions to clarify trends and traditions in hospitalization strategies for pediatric patients was sent via email on January 14, 2019, to all heads of ENT departments who were also members of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO). The electronic survey was designed by the Pediatric Working Group of the DGHNO.The response rate was 72.9% (120/166), one response was excluded because it was not provided via the online tool. Children are currently transferred to pediatric clinics after surgery in 64 of 120 otorhinolaryngology departments, a tradition in existence for at least 5 years in 48 of the 64 departments. In the remaining 56 institutions, children remained in the otorhinolaryngology department despite 30 having specialized pediatric clinics or clinics for pediatric surgery. This strategy is expected to be discontinued in 5 of the 56 hospitals in due course. A separate pediatric ENT clinic within the same institution is uncommon (27/120). The average travel time of on-call physicians in cases of postoperative bleeding is 3.4 min; transportation of the child to the emergency operation room takes 5.4 min on average. The nursing staff is predominantly responsible for transportation of pediatric emergency patients (109/120). The wards and operation rooms are commonly located in the same building, but on different floors (83/120).There is currently no uniform hospitalization strategy for postoperative care of children who undergo typical otorhinolaryngologic interventions in Germany.

Nach der haufig durchgefuhrten Tonsillotomie (TT) entsteht das Risiko eines Rezidivs der Tonsillenhyperplasie sowie von Tonsillitiden im verbleibenden Tonsillengewebe, weswegen im Verlauf eine sekundare Tonsillektomie (TE) erforderlich werden konnte. Es sollten umfassende Studiendaten zusammengetragen werden, um Fragen zu Indikationen/Kontraindikationen, Instrumentarium, Risiken, Komplikationen und weiterem Forschungsbedarf zu klaren. In der Literaturdatenbank PubMed wurde mit relevanten Suchbegriffen nach englisch-/deutschsprachigen Publikationen gesucht, die zwischen 1960 und 2016 publiziert wurden. Unter Berucksichtigung definierter Ausschlusskriterien verblieben insgesamt 104 Artikel. Es liesen sich 13.270 Patientendaten nach TT mit 11.485 Patientendaten nach TE unter Anwendung verschiedener Interventionstechniken vergleichen. Die Patienten waren zwischen 6 Monate und 78 Jahre alt. Am haufigsten waren in den 90 Kollektiven die Eingriffe wegen einer Tonsillenhyperplasie mit (20) und ohne (60) anamnestischen Tonsillitiden indiziert worden, in 7 Studien diente die TT der Therapie von Tonsillitiden, in 3 Artikeln fehlte die Indikationsbezeichnung. Revisionspflichtige Blutungen nach TT ereigneten sich durchschnittlich in 0,2 % der Falle. Die symptomatische Tonsillenhyperplasie ist die dominierende Indikation zur TT. Altersgrenzen fur die Verfahren und Beschrankungen auf bestimmte Operationstechniken lassen sich nicht begrunden. In Bezug auf Operationszeit, intraoperativem Blutverlust und Outcome erscheint die TT der TE uberlegen. Die TT zeigte zudem eine hohe Erfolgsrate. Forschungsbedarf ergibt sich fur die Beurteilung des langfristigen Erfolgs bei schlafbezogenen Atmungsstorungen sowie bei rezidivierenden akuten Tonsillitiden.

Photo documentation of hypertrophic tonsils is requested by some insurance companies to justify reimbursement of tonsillotomy. In 2017, a standardized photo documentation was introduced in tonsillotomy patients to verify the indication and effectiveness of the procedure.Using the archived photo documentation, this study aimed to evaluate the impact of two different positions of the mouth gag on the oropharyngeal airway.Pictures were taken through the operating microscope after insertion of the mouth gag but without suspension (D1), after suspension before tonsillotomy (D2), and after resection of tonsillar tissue with the mouth gag under tension (D3). For each picture, a 10-mm scale from a single-use paper ruler was placed on the uvula. For this retrospective study, the patient's images were inserted into PowerPoint slides. Distances were measured with the use of an inserted rectangular grid.The files of 149 patients undergoing tonsillotomy in a 6-month period were eligible for evaluation. Gender was balanced. The youngest patient was 16 months, the oldest patient 48 years old (mean: 6.95 years; median: 5 years). In all patients, tension of the mouth gag had significantly widened the oropharyngeal diameter (p 0.001), making the tonsils appear smaller.Suspension of the mouth gag results in a significant relative "downsizing" of the tonsils due to expansion of the oropharynx. Intraoperative photo documentation should also be performed without suspension of the mouth gag. Further studies may clarify whether stretching of the oropharynx has an impact on the distance between the tonsils and surrounding greater arteries.

Short-term results from seventy-six patients receiving a bone-anchored hearing implant installed with a novel minimally invasive surgery technique

Die Standardeingriffe Septumplastik, Tonsillektomie, Adenotonsillektomie und Halslymphknotenentfernung zahlen zu den 50 haufigsten stationar durchgefuhrten Operationen in deutschen Krankenhausern. Zunehmend haufig werden Tonsillotomien vorgenommen. Insgesamt handelt es sich um etwa 380 000 Eingriffe im Jahr. Diese Abhandlung soll sich mit Fehlern und Gefahren von Tonsillektomie (TE), Adenotomie (AT), Tonsillotomie (TT), Septumplastik (SP) und Halslymphknotenentfernung (LK) auseinandersetzen. Es wurden samtliche Gutachterkommissionen, Medizinische Dienste der Krankenkassen und Institute fur Rechtsmedizin in Deutschland um anonymisierte Datenubermittlung zu Fallen nach TE, TT, AT, LK und SP per Anschreiben gebeten. Die Resultate sollten vor dem Hintergrund der aktuellen medizinischen Literatur und publizierten Gerichtsurteilen im Zusammenhang mit diesen Operationen diskutiert werden. Die Antwortrate auf unsere Umfrage lag insgesamt bei 55,9%. Insgesamt wurden 9 Falle aus der Rechtsmedizin (Sektionsprotokolle), 49 von den Gutachterkommissionen und kein Fall vom MDK genannt. In allen 9 Fallen der rechtsmedizinischen Institute handelte es sich um todlich verlaufene Blutungskomplikationen nach TE. Hierunter befanden sich 2 Kinder im Alter von 5 und 8 Jahren sowie 7 Erwachsene im Alter zwischen 20 und 69 Jahren. Die zum Tode fuhrenden Blutungsereignisse hatten sich durchschnittlich nach 8,7 Tagen ereignet, in 4 Fallen zuhause (5., 8., 9., 17. Tag). In 6 Fallen war den Blutungen mindestens eine revisionsbedurftige Blutungskomplikation vorausgegangen. Die von den Gutachterkommissionen bearbeiteten 49 Behandlungsfehlervorwurfe betrafen TT (1), AT (4), LK (3), SP (16) und TE (25). Letale Verlaufe befanden sich nicht darunter, nur in 3 Fallen wurden uberhaupt Behandlunsgfehler bejaht (6,1%). Hierbei handelte es sich um eine N.accessoriuslasion nach LK, eine falsche OP-Indikation und einen Zahnschaden nach TE. Die Recherche in den juristischen Suchmaschinen ergab 71 publizierte Urteile. Hierunter fanden sich 29 nach AT und TE, 28 nach LK und 14 nach SP. Von den 71 Verfahren fuhrten 37 zu Verurteilungen wegen Behandlungsfehlern nach LK (16; 57%), TE (11; 41%), SP (8; 57%) und AT (2; 100%). Unter den 27 TE-Verfahren finden sich 16 wegen Blutungskomplikationen, nur 2 davon hatten sich am OP-Tag ereignet. Wegen der Blutungskomplikationen verstarben 5 Patienten, 5 behielten ein apallisches Syndrom zuruck. Die Klagegrunde nach SP waren sehr heterogen, am haufigsten wurden Aufklarungsmangel (6), Riechstorungen (4), Septumdefekte (2), Schadelbasisverletzung (2) und Austrocknung der Nase (2) vorgeworfen. Die 28 Verfahren nach LK befassten sich ausschlieslich mit Accessoriusschaden, Aufklarungsmangel wurden in 19 Verfahren vorgeworfen. Zu Schmerzensgeldzahlungen wurden die beklagten in 7 von 29 AT/TE-Verfahren, 9 von 28 LK-Verfahren und 6 von 14 SP-Verfahren verurteilt. In keinem Fall nach AT/TE fuhrten Aufklarungsmangel zur Verurteilung, wohl aber in 11 Verfahren nach LK und 2 SP-Verfahren. In Deutschland ist eine zufriedenstellende Ubersicht zur Komplikationsdichte und Haufigkeit juristischer Auseinandersetzungen der genannten Standardeingriffe nicht erhaltlich. Es muss davon ausgegangen werden, dass nicht jede Auseinandersetzung oder jede Komplikation in medizinischen oder juristischen Publikationsorganen veroffentlicht wird. Ein Behandlungsfehlervorwurf ist bei den untersuchten Standardeingriffen ausergerichtlich in weniger als 6%, gerichtlich in etwa der Halfte der Falle begrundet. Medizinische Beratung, Indikationsstellung, Aufklarungsgesprach, Operationsausfuhrung und Nachsorge mussen luckenlos dokumentiert werden, um als Operateur bei juristischen Auseinandersetzungen bestehen zu konnen. Vor allem bei der TE muss fur ein adaquates Komplikationsmanagement Sorge getragen werden. Dies beinhaltet auch Verhaltensmasnahmen der Patienten(eltern) im Fall der Nachblutung, transparente Anweisungen fur die Ablaufe in der Abteilung, Bereithalten von Instrumentarium und Airway-Management. Die stationare Behandlungsdauer darf individualisiert werden. Operative Techniken beeinflussen die Charakteristik der Nachblutungen, die jahrlich einer Analyse unterzogen werden sollten. Das Fehlen von definierten medizinischen Standards zur Schonung des N.accessorius fuhrt gelegentlich zu widerspruchlichen Einschatzungen der Gutachter, denen die Gerichte in den Urteilverkundungen in der Regel folgen.

Tonsillotomy procedures (TT) are being increasingly performed owing to the low postoperative morbidity compared with extracapsular tonsillectomy (TE). Patients may experience regrowth of tonsillar tissue or tonsillitis in the tonsillar remnants eventually resulting in a secondary tonsillectomy.A review of the literature was undertaken to evaluate the current indications and contraindications, surgical instruments, risks of surgery, and the need for further research related to TT.A search of the PubMed database was performed with the following terms: "tonsillotomy," "partial tonsillectomy," "subtotal tonsillectomy," "intracapsular tonsillectomy," "RFITT," and "tonsil ablation." Filters included language (English; German) and publication date (1960-2016). Articles were excluded if they were not related to tonsil surgery, did not provide clinical data, dealt with uncommon surgical techniques, or presented only data from polysomnographic studies.In all, 104 papers encompassing 97 studies and seven national surveys were eligible for analysis. In total, 13,270 patients had undergone TT and were compared with 11,485 patients after TE. Partial resection of the tonsils was most commonly accomplished with a microdebrider (51.5 %), and less frequently with coblation (20.5 %), radiofrequency (9.1 %), COTT is predominantly indicated for tonsillar hyperplasia, with or without tonsillitis. Restrictions related to age or surgical instruments are not reported in the literature data. Data concerning operation time, intraoperative bleeding, and outcome favor TT over TE. The median values for regrowth (3.0 %), postoperative tonsillitis (2.85 %), and secondary TE (1.37 %) emphasize the high success rate of TT. Further research utilizing a uniform terminology is mandatory to clarify the benefit of TT over TE in the long term and to resolve sleep-related breathing disorders resulting from tonsillar hyperplasia or tonsillitis.

Tonsillectomy rates vary considerably among different states, regions and times. This study was undertaken to identify the prevalence of "chronic" tonsillitis, peritonsillar abscess, hyperplasia of the tonsils with and without adenoids in absolute and relative numbers in an 80m people nation. Moreover, the number and rates of different surgical procedures to resolve either "chronic" tonsillitis, peritonsillar abscess or upper airway obstruction due to (adeno)tonsillar hyperplasia over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy , abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was determined and analyzed in relation to age and gender..Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013..The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142.574 (in 2000) to 87.624 in 2013 (38.5 %). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833.896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120.993 in 2006 to 84.332 procedures in 2013 (30.3 %). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10.000 in 2010 to 58.68 per 10.000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10.000 to 10.90 per 10.000. In contrast, an increasing number of tonsillotomies was performed between 2007 (4.659 procedures) and 2013 (11.493). The cumulated number of procedures was 59.049. A constant number of 15.000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100.000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced by 5.98% of all patients after 245.721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06 % vs. 7.02 %). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only.chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continullay, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (10 years). The study reveals a dramatic change mandating further surveillance by insurance companies and authorities in the national health system of an 80m people nation..

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.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.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.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.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive or tic disorders associated with streptococcal infections. Because otolaryngologists evaluate a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was undertaken to evaluate the efficacy of tonsillectomy in patients presenting with a verified PANDAS.A PubMed research was performed using search terms "tonsillectomy" and "PANDAS", "OCD", "compulsive", "pediatric autoimmune", "Chorea" and "Tic" limited by publication date January 1, 1995 to July 31, 2015. Reviews without patients were not included in the review.Nine papers matched our search terms, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor for TE, but this was by far not supported by the findings in the case series. The follow-up ranged form 2-36 months (case reports) and 24-36 months (case series).establishing the diagnosis of PANDAS is complicated by underlying co-morbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity and unavoidable mortality rate it appears wise to indicate TE only in clinical studies with standardized inclusion criteria.

Hintergrund: Auf Grund der anatomischen Enge, fehlenden Mitteilungsmoglichkeit und besonderen Belastung durch die Untersuchung stellt der Peritonsillarabszess (PTA) insbesondere bei sehr jungen Kindern eine Herausforderung dar. Ziel dieser Untersuchung war es, die Blutungskomplikationen der Tonsillekomie a chaud (TAC) bei Kindern

Hintergrund Dysphagie und Globusgefuhl sind ein haufiges Krankheitsbild mit breit gefacherter Pathogenese von funktionellen Storungen bis zu Malignomen. Zur Klarung ist ein interdisziplinares Vorgehen erforderlich. Wegen der geringen Inzidenz nehmen Gefaserkrankungen bei Schluckstorungen noch einen untergeordneten Stellenwert ein.

Angiofibromas in the head and neck area usually arise in the nasopharynx (NA) in adolescent males. They may also occur outside the nasopharynx (ENA) and can therefore be misdiagnosed. An ill-advised biopsy may result in brisk bleeding. This study was undertaken to evaluate the incidence and clinical features of ENA.A review of the international literature was performed.A total of 65 patients with ENAs from 16 different countries were reported in the literature. Two patients had a congenital lesion, the oldest being 78 years old. A total of 48 patients were male (73%). The maxilla was the most commonly affected site (24.6%), with the ethmoid, nasal cavity or septum and other sites being involved less frequently. Symptoms arose in 40 patients within 6 months. Among a wide variety of symptoms, epistaxis with or without nasal obstruction was reported for 18 patients. Brisk bleeding resulting from a total of 23 biopsies occurred in 13 patients, and required blood transfusion in 11. Death was reported for two patients as a result of acute respiratory compromise and endocranial extension.ENAs are extremely rare compared to NAs and have to be acknowledged as a different entity. In comparison to patients with NAs, as female adults are affected, the lesion is diagnosed earlier and is less vascularized and the patients are older. Surgical resection is sufficient treatment due to a tendency for local and less aggressive growth.

Hintergrund Potenziell ambulant durchfuhrbare Eingriffe stellen fur Kliniken der hoheren Versorgungsgruppen nicht zuletzt aus finanziellen Grunden eine logistische Herausforderung dar. Die Adenotomie als Einzel- oder Kombinationseingriff zahlt mit zu den haufigsten Operationen unseres Fachgebietes und fallt unter diese Kategorie. Ziel dieser Untersuchung war es, die an unserer Klinik angewandten Kriterien zur Festlegung der stationaren Versorgung nach Adenotomie hinsichtlich Zuverlassigkeit und Anderungsmoglichkeit zu uberprufen sowie die Rate von Blutungskomplikationen zu ermitteln.

Hintergrund. Spontan entstandene Liquorfisteln sind aus der Literatur als seltene Einzelfallbeschreibung bekannt. Ihre Diagnosestellung hangt vom Verdacht und Kenntnisstand des Untersuchers ab. Zur Evaluierung charakteristischer Symptome dieses Krankheitsbildes ist eine Zusammenfassung der zahlreichen Einzelfallschilderungen wunschenswert und sollte mit der vorliegenden Untersuchung auf einen aktuellen Stand gebracht werden.

Hintergrund. Eine persistierende Liquorfistel der Laterobasis ist umgehend operativ zu sanieren, da der Patient durch eine potenziell lebensgefahrdende Meningitis bedroht ist. Traumen und Operationen sind die haufigsten Ursachen, weniger haufig sind chronische Infektionen und Tumoren. Die sehr seltene spontane Liquorfistel muss in die differenzialdiagnostischen Uberlegungen aufgenommen werden.

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e., tonsillotomies) are increasingly performed. The aim of this study was to evaluate alleged medical malpractice, technical traps and pitfalls associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications or medico legal implications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published verdicts in Germany.The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed 9 cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including 2 children (5 and 8 years of age) and 7 adults (aged 20-69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; 4 patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. 3 Conciliation Boards submitted expert opinions concerning cases TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only 3 of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (11; 41%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials based on LN were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thorough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff, readily available surgical instruments and appropriate airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

The aim of the present evaluation was to analyse a large patient population with nasal bone fractures leading to surgical reposition of the nasal bone. Special attention was paid to age summit, the distribution of the seasons, the rate of open compared to closed nasal bone fractures, accompanying injuries, diagnosis and therapy as well as to the postoperative course.A total of 300 patients was evaluated retrospectively. All patients had been treated between 1999 and 2004 regarding simple and complex nasal bone fractures. Data were analysed with regard to history, age, gender, diagnosis, therapy, results, and complications.The average age of the patients was 29.6+/-15.6 years at the time of fracture with clear predominance of the male gender (77%). Another age summit could be observed in patients of60 years. The main reasons for nasal bone fracture were falls (30%), in elderly patients often caused by cardiac syncopes, and rows (28%). The most frequent findings were deviation of the longitudinal axis of the nose (59%) and traumatic deviation of the nasal septum (50%). 65 patients (22%) had open nasal bone fractures, in 5% of the cases septal hematoma could be observed.Closed reposition of the nasal bone is the therapy of choice in uncomplicated nasal bone fractures. Special attention has to be paid to the group of patients aged 60 years and older who often suffer from treatment requiring comorbidities. In these cases inpatient treatment must be considered.

Blutungen nach Adenotomie und Tonsillektomie sind nach wie vor als Komplikation dieser Eingriffe gefurchtet. Da bis zum Zeitpunkt der Operation unentdeckte Gerinnungsstorungen ein Risiko fur Nachblutungen darstellen, erfolgt nicht zuletzt aus medikolegalen Grunden oftmals die praoperative Bestimmung von Prothrombinzeit (PTT), Quick-Wert und Thrombozytenzahl. Wie auch in der „Gemeinsamen Stellungnahme zur Notwendigkeit praoperativer Gerinnungsdiagnostik vor Tonsillektomie und Adenotomie bei Kindern“ der Deutschen Gesellschaft fur Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie ausgefuhrt, wird dieses Thema durchaus kontrovers diskutiert und bisher bestand leider keine Einigkeit uber ein standardisiertes Vorgehen. In dieser Stellungnahme wird festgehalten, dass im Kindesalter, sofern die grundliche Anamnese keinen Hinweis auf eine Gerinnungsstorung ergibt, primar auf eine laborchemische Gerinnungsanalyse verzichtet werden kann ( http://www.hno.org/kollegen/gerinnung_te_ae.html ). Unsere Untersuchung soll dazu beitragen, den Zusammenhang zwischen Blutungskomplikation einerseits und praoperativ bestimmten Routineparametern der Gerinnung bzw. auffalliger Blutungsanamnese andererseits bei Kindern und Erwachsenen abzuschatzen. Bei 688 Patienten wurden praoperativ sowohl eine durch Fragebogen standardisierte Anamnese erhoben, als auch die Werte fur Quick und PTT sowie die Thrombozytenzahl bestimmt, um mogliche Gerinnungsstorungen aufzudecken. Blutungskomplikationen wurden dann mit anamnestischen und laborchemischen Auffalligkeiten des Gerinnungsstatus in Beziehung gesetzt. Die Gerinnungsanalyse ergab bei 649 der 688 Patienten normale Parameter, bei 39 (5,7%) Patienten fanden sich auch in der Kontrollbestimmung pathologische Werte. Bei 6 dieser 39 Patienten stellten wir im Rahmen der detaillierten Gerinnungsanalyse tatsachlich vorher nicht bekannte Gerinnungsstorungen fest, die allerdings nur beim Auftreten einer Blutungskomplikation korrekturbedurftig waren. Bei weiteren 15 Patienten war ein klinisch relevanter Faktorenmangel bereits bekannt und in keinem weiteren Fall lagen anamnestische Auffalligkeiten vor, so dass insgesamt 21 Patienten mit einer klinisch relevanten und im Falle einer Blutungskomplikation korrekturbedurftigen Gerinnungsstorung operiert wurden. Nur bei 8 (38%) dieser 21 Patienten zeigten sich in der praoperativen Bestimmung von Quick, PTT und Thrombozytenzahl pathologische Werte. Insgesamt mussten 12 Nachblutungen (1,7%) operativ versorgt werden; bei allen diesen Patienten lagen normale Gerinnungswerte sowie eine unauffallige Anamnese vor. Die haufig eingesetzte praoperative Bestimmung von Routineparametern der Gerinnung (PTT, Quick und Thrombozytenzahl) ist weder geeignet gegebenenfalls korrekturbedurftige Gerinnungsstorungen sicher aufzudecken noch Blutungskomplikationen nach Adenotomie oder Tonsillektomie vorherzusagen.

Controversy surrounds the question of which technique should be preferred for tonsillectomy in order to reduce postoperative morbidity in terms of pain, bleeding, activity and return to normal diet. This study reviews the current literature on coblation tonsillectomy (CTE).All studies published in peer-reviewed journals reporting postoperative morbidity following CTE until July 2006 were included in our study.A total of 21 studies matched our search criteria but there were excluded from further analysis because coblation was used only for volume reduction of the tonsils. Reduced morbidity was registered in eight studies, two could not identify any difference and five studies reported an increased postoperative morbidity. Seven different surgical procedures were compared in 17 studies to CTE. The patients were not followed-up in four studies and the follow-up exceeded 1 week in nine studies only. Wound inspection was performed in four studies and a better wound healing reported in two of these, but by the same authors. Postoperative bleeding requiring surgical treatment under general anaesthesia occurred with an incidence of 0% to 11.5%. Secondary bleeding (24 h) prevailed in all but two studies. Postoperative pain was evaluated in ten studies with conflicting results.The design of the current studies varies in size, age distribution, indications for surgery, the surgical techniques compared and follow-up. The results are heterogenous and further evidence is still required to show that CTE is a safe alternative. Therefore, calculation of cost-effectiveness of a commonly performed expensive CTE as a new standard technique is currently impossible.

The introduction of coblation tonsillectomy (CTE) may contribute to reduce the postoperative morbidity in terms of pain, delayed oral intake and bleeding.A prospective pilot study was undertaken to evaluate the clinical course by inpatient observation (5 days) and telephone contact 6 months after CTE. The data from 61 patients (aged 44 months-69 years) were analyzed. The patients were grouped into those with surgical care of bleeding (A), non-surgical care of bleeding (B), and no bleeding event (C).The study was terminated early due to major bleeding complications in seven patients (A). Fifteen patients experienced minor (B) and 41 no (C) bleeding episodes. In the interview, 29 patients identified pain, lasting 16.7 (A), 11.6 (B) and 11 (C) days, as the most significant complication of surgery.The introduction of CTE was followed by a dramatic increase in major bleeding complications, including late bleeding episodes. Pain following tonsillectomy remains a problem to be solved by further techniques. We will continue to perform the cold dissection technique.

The new technique of ILM-guided vocal cord biopsy and APC is safe, cost-effective and non-invasive. It provides excellent airway control, adequate exposure of the vocal cords and effective treatment of laryngeal bleeding.Suspension microlaryngoscopy is a standard diagnostic procedure for vocal cord biopsy. In experienced hands failure of the procedure is extremely rare and may indicate a need for more invasive techniques. The aim of this study was to present a new technique of laryngoscopy/vocal cord biopsy and to review the relevant literature.After induction of general anesthesia and preoxygenation an intubation laryngeal mask (ILM) was inserted. A flexible bronchoscope was passed through the ILM and an anterior lesion was identified at the vocal cord. Biopsies were taken with forceps inserted through the instrument's working channel. The procedure was performed using video-endoscopic guidance. Bleeding from the wound surface was adequately treated with argon-plasma coagulation (APC).Identification of the vocal cords was readily accomplished using the ILM. Only four literature reports matched our search criteria; all used the standard laryngeal mask or other instruments such as a laser or did not use the procedure for definitive therapy.

Peritonsillar abscess (PTA) is the most common deep neck space infection treated by otolaryngologists affecting predominantly young adults. Children present a challenge owing to the difficulty in obtaining an exact history and adequate physical examination. Particularly for the pediatric age group controversy surrounds the question of optimal treatment. This study was undertaken to evaluate bleeding complications following immediate tonsillectomy (TAC) in a pediatric population (16 years) of age and to compare our management protocol with the current status in the literature.The data of 218 children who had undergone TAC between January 1988 and January 2003 in our clinic were enrolled in a retrospective study. The youngest patient was 18 months, the oldest 15.9 years of age (mean: 14.53; median: 14; STD: 12.11 years). 95 patients were male (43.6%), 123 female (56.4%). Various treatment protocols of the current literature are addressed.Postoperative hemorrhage (all from the opposite side) requiring surgical treatment under general anesthesia occurred in 4 children (1.8%). Repeated hemorrhage did not occur, blood transfusions were not required, there was no case with lethal outcome. Several reports indicate that needle aspiration (NP) or incision and drainage (ID) may suffice for the majority of cases but do not distinguish between different treatments for children and adults. More recently, conscious sedation has become a great support for pediatric treatment protocols.The initial success rates of NP or ID are both very high (90%) and the overall recurrence rate is low, particularly in children. Only for selected subgroups, patients may profit from TAC, which was clearly not associated with an increased risk of bleeding in our pediatric population.

Angiofibromas commonly arise in the nasopharynx in young male patients. Diagnosis is widely based on radiographic imaging to avoid ill-advised biopsy which may result in brisk bleeding. This study was undertaken to evaluate the incidence, clinical features and complications that may occur during the process of diagnosis and surgical therapy of angiofibromas outside the nasopharynx.Case report of a 13-year-old female patient and review of the literature.Our patient received multi-agent chemotherapy elsewhere due to a misdiagnosed angiofibroma. Computed Tomography (CT) revealed a maxillary tumor which was repeatedly biopsied. Hypervascularity was excluded by arteriography and the lesion removed after lateral rhinotomy. The data of 42 patients were analyzed including our own case. 32 patients were male, 10 female. The majority became symptomatic aged 19 years or younger (71.4 %). The maxilla was most commonly affected (38 %), less frequently the ethmoid, nasal cavity or septum, beside others. In 38 patients, symptoms developed within 12 months or less (average: 8.5 months). Epistaxis, nasal obstruction and facial swelling were reported for most patients. Brisk bleeding occurred in 10 patients during tumor removal and resulted from biopsies in 11 of 20 patients. Angiography detected hypervascularity in 3 of 4 patients. There was no case with lethal outcome.Extranasopharyngeal angiofibromas of the nasal cavity or paranasal sinuses should be included in the differential diagnosis of nasal tumors. Compared to nasopharyngeal angiofibromas, more female patients are involved, symptoms develop more quickly but hypervascularity is less common. Signs of questionable hypervascularity in Computed Tomography and Magnetic Resonance Imaging (MRI) should indicate arteriography prior to surgical procedures. Preoperative embolization of hypervascular lesions during arteriography will reduce the risk of brisk bleeding during biopsy or surgical tumor removal.

Dysphagia may be due to oral, pharyngeal or esophageal dysfunction and poses a frequent problem for the otolaryngologist. Motor disturbances, structural disorders, functional problems, congenital lesions and malignancies have to be excluded in an interdisciplinary diagnostic approach. Currently, vascular diseases play a minor role in the diagnosis of dysphagia.A 70-year-old female presented with constant dysphagia and a foreign body feeling in the throat of about 2 months duration. Palpation and ultrasound revealed a tumor situated in the right supraclavicular region. The lesion was identified as a true aneurysm of the subclavian artery by digital subtraction angiography. Successful resection and reconstruction was accomplished using a PTFE graft.Aneurysms of the subclavian artery are rare and in most cases related to thoracic outlet syndrome (TOS) or arteriosclerosis. It can be assumed that an increasingly aged population will present with an increasing incidence of diseases related to atherosclerosis. Moreover, the increasing incidence of specific infections may contribute to this phenomenon. This neglected disease should be included in the differential diagnosis when dealing with supraclavicular lesions, foreign body feeling or dysphagia.

Objective: To evaluate the clinical features and incidence of true myxomas affecting the lateral skull base. Material and Methods: Illustrative case report and review of the relevant literature. Included are all reports of myxomas according to the histopathologic definition of Stout. Results: Despite nine case reports, only four patients matched the histopathologic criteria of a true myxoma growing in the lateral skull base. Facial palsy occurred in three adults with additional otalgia in one and progressive hearing loss (HL) in another patient. Our patient initially presented with signs of recurrent otitis media. The mastoid cavity was involved in all patients. Conclusion: Differential diagnosis of lesions occurring in the lateral skull base should include true myxoma. Correct diagnosis should be based on immunohistopathology to rule out malignant tumors. Radical surgery is the treatment of choice, but surgeons should respect vital structures and esthetic consequences.

Chondrosarcomas of the larynx (CS) are uncommon and predominantly affect the cricoid cartilage. In the larynx they have a distinctive biological behaviour and require individual treatment. A retrospective study was made on three cases of CS, all presenting with compromise of the upper respiratory tract. The medical history varied from several weeks to six years. Correct diagnosis required open resection of the lesion in all cases. Due to intra-operative findings, all patients underwent total laryngectomy. CS grow slowly and are therefore frequently diagnosed late in the course of the disease. A subglottic bulging of the mucosa should indicate high-resolution-computed-tomography of the larynx to exclude affection of the laryngeal framework. Correct diagnosis of laryngeal cartilaginous tumours requires a complete examination of the entirely resected tumour. Only extended and de-differentiated CS indicate further radical surgery, the remainder call for conservative surgical management.

Adenoidectomy, with or without tonsillectomy, remains as one of the most common surgical procedures. This study was undertaken to determine whether or not the criteria for adenoidectomy based on an inpatient basis in our hospital have to be revised and to evaluate the incidence of postoperative bleeding.The data of 470 patients who underwent adenoidectomy during 1 year were analyzed in a prospective study. Age1 year; age16 years; underlying diseases that put the patient at increased pre-or postoperative cardiopulmonary, metabolic or general risk;20 minutes driving time between hospital and home, lack of compliance; request of the patients/parents were criteria for adenoidectomy to be performed as an inpatient procedure. Due to the rarity of postoperative bleeding the rate of post-adenoidectomy hemorrhage was calculated in a retrospective study on the basis of the data of 8131 patients who had undergone adenoidectomy.A total of 249 patients underwent adenoidectomy on an outpatient basis (53%). Two patients required surgical treatment for postoperative bleeding under general anesthesia (0.43%), one of whom was initially scheduled for outpatient surgery. The parents of 17 children initially scheduled for outpatient surgery refused to take responsibility of postoperative care on the day of surgery. These children were admitted. Inpatient observation was scheduled in most cases because of the distance to the hospital (115 patients) or underlying diseases (7 patients). The rate of post-adenoidectomy hemorrhage in our retrospective study was 0.23%. There was only one adult with repeated bleeding on the day of surgery and 6 days postoperatively. 15 of 19 episodes of bleeding occurred on the day of surgery, the latest episode 6 days postoperatively. There was no case with lethal outcome. No blood transfusions or major surgical procedures at the neck were required to stop the bleeding.Inpatient observation should be considered in patients with underlying general diseases, postoperative bleeding, poor compliance or request of the patients/parents. Age, general risk of post-adenoidectomy hemorrhage and distance to the hospital are not criteria significant enough to indicate inpatient observation in patients who undergo adenoidectomy.

Tumors of the parapharyngeal space encompass a wide variety of benign or malignant neoplasms. The purpose of this study was to evaluate our experience with the history, diagnosis and management of parapharyngeal tumors.In a retrospective study the data of 19 patients who underwent surgical excision between 1995 and 2001 were analyzed with regard to presenting signs and symptoms, histologic diagnosis, imaging technique and surgical approach. 12 patients were female, 7 male. The youngest patient was 17, the oldest 72 years of age (mean: 47).Two thirds of the resected tumors were benign. Eight tumors originated from salivary glands, neurogenic tumors were found in 6 patients, malignant lymphomas in two cases. CT was performed in 16 patients, an additional MRI was indicated in 5 patients due to the superior soft-tissue resolution. In one patient arteriography revealed a paraganglioma. Preoperative localization of the tumor was possible in all cases. The transcervical approach was performed in the majority of cases (7). An intraoral excision (4) in combination with a transcervical approach (3), transcervical-tarnsmandibular (1) or a midfacial degloving (2) was performed less frequently.Benign parapharyngeal tumors prevail. In the majority of cases they originate from the salivary glands. CT and MRI are the diagnostic procedure of choice to select the surgical approach with the least morbidity. MRI should be preferred since it provides superior soft-tissue resolution, multiplanar imaging, identification of the vascular structures and no exposition to ionizing radiation. Arteriography should be performed if indicated by MRI findings. Incisional biopsy or fine needle biopsy should be performed only in cases which appear to be unresectable. Intraoral excisions should be indicated only for small tumors. The majority of tumors can be excised using the transcervical approach. Excessive tumor growth or tumors growing close to the skull base may indicate an infratemporal approach or a mandibulotomy.

Isolated cases of spontaneous cerebrospinal fluid otorrhea (SCFO) of temporal bone origin with or without meningo(encephalo)cele have been reported. Diagnosis is predicted on a high index of suspicion. Since meningitis may occur secondary to SCFO, optimal therapy with surgical closure of the defect should immediately be performed. This study was undertaken to evaluate the incidence, characteristics and type of SCFO in literature.We reviewed the reports on SCFO in the world literature since the first description in 1897 by Escat. Clinical presentation, gender, age and surgical management were aspects of our classification. Not included were patients with cerebrospinal fluid leak following any kind of previous temporal bone surgery, head trauma or rupture of the round window membrane.A total of 241 CSFO in 236 patients were found to accomplish the search criteria. Gender was not found to be a risk factor. Two subtypes of SCFO exist: the majority (161 cases) developing through the tegmen tympani and a smaller number (80 cases) with a translabyrinthine SCFO. The latter group can be regarded as the childhood-type with congenital defects of the otic capsule (Mondini dysplasia) presenting with meningitis in 85% of all cases. Adulthood-type SCFO are typically located in the tegmen tympani area presenting with conductive hearing loss or otorrhea following tube placement in 86% of all cases. Recent literature recommends a combined (transmastoidal and middle fossa) approach for closure of defects in the tegmen.Copious otorrhea through a perforated tympanic membrane or following placement of a ventilation tube, conductive hearing loss or meningitis without impairment of cochlear or vestibular function should be regarded as warning signs for an existing SCFO in adults. Children usually present with symptoms of inner ear anomalies, meningitis and loss of cochlear-vestibular function. High-resolution computer tomography is the diagnostic procedure of choice. A follow-up of several years to disclose any recurrence of SCFO or occurrence at a different area should be considered in any patient.

Spontaneous cerebrospinal fluid otorrhea (SCFO) or rhinorrhea originating from laterobasal defects is uncommon. An immediate closure of the defect is mandatory due to the risk of life-threatening meningitis. The purpose of this paper is to review the literature and to present two additional case reports with emphasis on diagnostic problems and surgical techniques.Two adults have been treated for SCFO in our clinic. A 62-year-old woman was complaining of pertinent otorrhea after placement of a ventilation tube and conservative treatment of serous otitis for 1 year elsewhere. A 66-year-old male patient had been treated for acute pneumococcal meningitis. He presented with unilateral deafness and vertigo 3 months later. High-Resolution-Computer-Tomography (HRCT) revealed a unilateral defect in the female and a bilateral defect in the male patient. A transmastoidal approach was used to amputate the meningoencephalocele and modified (Mini-Craniotomy) in the second (male) patient. The defect was closed in two layers using allogenic material and fibrin glue.One year after surgery both patients were free of symptoms and defect closure remained stable in HRCT and under microscopic view.SCFO from tegment defects is an uncommon cause of otorrhea and even rhinorrhea. History and clinical presentation of our patients can be regarded as typical for adults with SCFO. Evaluation of history, HRCT and a high index of suspicion is a prerequisite for correct diagnosis. The approach (transmastoidal, transtemporal, Mini-Craniotomy) to repair leaks of the tegmen should be related to the extent of the defect.

Episodes of post-tonsillectomy hemorrhage are unpredictable and potentially life-threatening. Primary post-tonsillectomy hemorrhage (24 hr postoperatively) is generally considered to be more common and more serious than secondary hemorrhage (24 hr). Therefore, recent studies have focused on the control of primary hemorrhage in order to determine the appropriate length of postoperative observation. The issue of follow-up is becoming more important in light of the increasing popularity of outpatient tonsillectomy. We undertook a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage over the short and long term (3 mo). We studied 602 patients, aged 23 months to 89 years (mean: 20.6 yr), who had undergone inpatient tonsillectomy in 1999 and who had been hospitalized for at least 5 days. Our goal was to ascertain the number of episodes of postoperative hemorrhage that required surgical treatment under general anesthesia. We were able to contact 601 of these patients (or their parents) by telephone 3 months postoperatively to inquire about any instances of delayed secondary bleeding. In all, 16 patients (2.7%) had experienced post-tonsillectomy bleeding that required surgically achieved hemostasis under general anesthesia. Of this group, 11 patients (68.8%) had experienced primary hemorrhage and were treated immediately, and five (31.3%) experienced secondary hemorrhage. One patient in the latter group experienced excessive bleeding 38 days postoperatively, which we believe is the latest episode of secondary bleeding reported to date. Based on the findings of this study, we believe that a postoperative follow-up period of 10 days is sufficient to identify all but the most rare cases of post-tonsillectomy hemorrhage.