[Tonsillectomy in children: preoperative evaluation of risk factors]. / Tonsillektomie bei kindern: präoperative evaluation von risikofaktoren.

Tonsillectomy is one of the most frequently performed surgical procedures in children and is associated with a relatively high risk of postoperative complications. The question often arises whether paediatric obstructive sleep apnoea should be diagnosed with preoperative sleep testing and whether preoperative coagulation tests should be performed in every child undergoing tonsillectomy. In order to answer these questions, the relevant German and English literature was analysed. Adenotonsillectomy in childhood usually resolves the underlying sleep-related breathing disorder. Nevertheless, especially in children with clinical risk factors such as severe sleep apnoea, obesity or craniofacial malformation, respiratory complications should be expected in the postoperative phase. Routine sleep tests prior to tonsillectomy are neither necessary nor practical for preoperative evaluation. Inherited coagulation disorders have only a limited effect on the occurrence of postoperative bleeding and the predictive value of routine coagulation tests is limited. As long as a thorough clinical history is negative, routine coagulation tests are not helpful or necessary prior to tonsillectomy in children.

[Polytrauma with tension pneumothorax with inserted chest tube]. / Polytrauma mit Spannungspneumothorax bei liegender Thoraxdrainage.

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.