[Epiglottitis in adults in general practice: difficult to recognise and life-threatening]. / Epiglottitis bij volwassenen in de huisartsenpraktijk: lastig te herkennen en levensbedreigend.

Epiglottitis is a rare and life-threatening cause of acute sore throat. Usually, epiglottitis is caused by a bacterium, such as Haemophilus influenzae type b. Symptoms of epiglottitis are acute and rapidly progressive sore throat, a hoarse voice, fever, and drooling. We present two adult patients with acute sore throat who were diagnosed with epiglottitis. In adults with symptoms compatible with epiglottitis, it is justified to look down the throat with a light. Only if the view is impeded should a spatula be used but carefully. If there is a discrepancy between the severity of symptoms and few or no abnormal findings on examination of the throat, epiglottitis should be considered. If epiglottitis is suspected, referral to an ENT specialist is always indicated. Symptoms of upper airway obstruction, such as drooling, dyspnoea, inspiratory stridor and fear or anxiety, are an indication for emergency referral by ambulance.

Adenotonsillectomy for upper respiratory infections: evidence based?

BACKGROUND: Despite high rates of (adeno)tonsillectomy for upper respiratory infections in western countries, the medical literature offers the physician little support in deciding which child might benefit from the operation. METHODS: A literature search was performed to identify randomised trials and non-randomised controlled studies into the efficacy of tonsillectomy with or without adenoidectomy in children under 18 years. For the outcomes sore throat episodes, sore throat associated school absence, and upper respiratory infections, pooled estimates of the incidence rate ratios and rate differences with 95% confidence intervals were calculated, assuming a Poisson distribution. RESULTS: Six randomised trials and seven non-randomised controlled studies on the efficacy of adenotonsillectomy in children were evaluated. For sore throat episodes data for 2483 person-years were available. The pooled risk difference was -1.2 episodes per person-year (95% CI -1.3 to -1.1). For sore throat associated school absence 1669 person-years were analysed. The pooled risk difference was -2.8 days per person-year (95% CI -3.9 to -1.6). For upper respiratory infections 1596 person-years were available. The pooled risk difference was -0.5 episodes per person-year (95% CI -0.7 to -0.3). CONCLUSIONS: All available randomised trials and non-randomised controlled studies into the efficacy of (adeno)tonsillectomy had important limitations. The frequency of sore throat episodes and upper respiratory infections reduces with time whether (adeno)tonsillectomy has been performed or not. (Adeno)tonsillectomy gives an additional, but small, reduction of sore throat episodes, days of sore throat associated school absence, and upper respiratory infections compared to watchful waiting.

Large international differences in (adeno)tonsillectomy rates.

This article compares recent paediatric and adolescent (adeno)tonsillectomy (T +/- Ads) rates in several countries of the European Union, the US, Canada and Australia. Trends in paediatric and adolescent surgical rates in the Netherlands and UK from 1974 to 1998 are studied as well. In 1998, the paediatric T +/- Ads rate varied from 19 per 10000 children in Canada to 118 per 10000 in Northern Ireland, while the adolescent rate varied from 19 per 10000 adolescents in Canada to 76 per 10000 in Finland. In the Netherlands, the paediatric T +/- Ads rate decreased rapidly between 1974 and 1985 and remained similar since. Ten years later, between 1985 and 1998, the adolescent T +/- Ads rate increased. In the UK, on the other hand, an increase in T +/- Ads was observed both in children and in adolescents. This study shows that paediatric and adolescent T +/- Ads rates still vary considerably between countries. There is no definitive evidence that decreasing rates of T +/- Ads in childhood are associated with tonsil-related disease, necessitating surgery, in later life.

Current indications for (adeno)tonsillectomy in children: a survey in The Netherlands.

OBJECTIVE: Despite the fact that (adeno)tonsillectomy is one of the procedures most frequently performed on children, studies of current indications are scarce. The purpose of this study is to determine the indications for (adeno)tonsillectomy in children younger than 15 years of age according to Dutch ENT surgeons and general practitioners (GPs). METHODS: During a period of 8 months, 18 ENT surgeons in seven ENT practices and 210 referring GPs filled out standard questionnaires for 349 children listed for tonsil surgery. RESULTS: Apart from recurrent tonsillitis (ENT: 40%, GP: 35%), findings such as enlarged tonsils (ENT: 42%, GP: 24%) and tonsillar crypt debris (ENT: 29%, GP: 17%) and non-specific symptoms such as listlessness (ENT: 28%, GP: 19%) and poor appetite (ENT: 28%, GP: 16%) were considered important criteria for surgery. Symptoms of obstructive sleep apnea were present in 25% (ENT) and 6% (GP) of patients but were considered indicative for surgery in only 11% (ENT) and 4% (GP). In contrast to ENT surgeons, GPs considered otitis media and hearing loss relatively important for (adeno)tonsillectomy. CONCLUSIONS: Apart from the generally accepted indications such as recurrent tonsillitis and obstructive sleep apnea, other indications play an equally important role in the decision to perform tonsil surgery in The Netherlands.

[Adenotonsillectomy in children: not yet scientifically validated]. / Adenotonsillectomie bij kinderen: nog onvoldoende wetenschappelijk onderbouwd.

Tonsillectomy, in 90% of cases combined with adenoidectomy, is one of the most frequently carried out operations on children in the Netherlands: in 1998 there were 33,471 operations in children aged 0-14 years. This high frequency is in stark contrast to the scientific basis for the efficacy of this intervention. A meta-analysis carried out recently revealed just one good study. The lack of scientifically based clinical guidelines, partly explains the large international and regional differences in the number of operations carried out. In the Netherlands only 35% of the children operated on satisfy one of the criteria for which the effectiveness of (adeno)tonsillectomy has been established: frequent recurrent tonsillitis or obstructive sleep apnoea. A project has been started in the Netherlands to further study the effectiveness of this intervention, the results of which must contribute to a more thoroughly substantiated indication.