扁桃体摘除术治疗IgA肾病的临床研究

目的：研究扁桃体摘除治疗IgA肾病的适应证、临床效果及安全性。方法：将207例经肾活检确诊为IgA肾病患者分为手术组及对照组,手术组患者术后治疗方案与对照组相同,随访时间为1年,观察两组病例的蛋白尿水平、红细胞数量及血压、肾功能情况变化。结果：手术组3个月后尿红细胞数量、尿蛋白定量明显好于对照组,手术组血压、内生肌酐清除率及对照组血压无明显变化,但对照组内生肌酐清除率则出现下降。结论：扁桃体摘除治疗合并慢性扁桃体炎的IgA肾病临床疗效肯定,对肾功能有保护作用。     

Gold laser tonsillectomy—A safe new method

Objectives

To determine if Gold laser tonsillectomy is an acceptably safe method of removing tonsils by comparing its complication rates to other established methods, namely Coblation tonsillectomy and cold steel dissection tonsillectomy.

Study design

A retrospective review of 748 consecutive patients, ages 2-18, undergoing tonsillectomy at a pediatric teaching institution.

Methods

Tonsillectomy with or without adenoidectomy was performed utilizing either the Gold laser (n = 435), Coblation device (n = 153), or by cold steel dissection (n = 160) between August 2005 and August 2007. Hospital charts were then reviewed to determine the rates of post-tonsillectomy hemorrhage and dehydration requiring hospital admission.

Results

In the Gold laser group there were 7 bleeding events (1.61%) and 7 dehydration admissions (1.61%). The Coblation group had 9 bleeding events (5.88%) and 1 dehydration admission (0.65%). The cold steel group had 1 bleed (0.63%) and 2 dehydration admissions (1.25%). The hemorrhage rate associated with Gold laser tonsillectomy was statistically equivalent to cold steel dissection (p = 0.3710) and significantly lower than in our Coblation control group (p = 0.0286).

Conclusions

Tonsillectomy by means of the Gold laser can be safely performed in the pediatric population.     

The development of sleep disordered breathing from 4 to 12 years and dental arch morphology

Objective

To track the development of sleep disordered breathing (SDB) as well as dento-facial morphology in cohort of children by having them complete a questionnaire at ages 4, 6 and 12. Clinical examination, sleep studies (at ages 4 and 12) and orthodontic evaluation were carried out on all who were reported to snore regularly and children who did not snore at all.

Results

Out of the original group of 615 children, 64% (393) answered the inquiry on all three occasions. Of those, 27 snored regularly and 231 did not snore at all at the age of 12. There were differences between those groups on all answers, especially prevalence of oral breathing: 78% versus 5% (p < 0.001). The prevalence of OSA decreased from 3.1% at the age of 4 to 0.8% at age 12 and the severity decreased from a mean AHI 14.8 at 4 to a mean AHI of 1.95 at age 12. The minimum prevalence of snoring regularly was estimated to 4.2% at 12 years compared to 5.3% at 4, calculated for the original cohort of 644 children. The odds for a child who snored regularly at 4 or 6 years to be snoring regularly also at age 12 was 3.7 times greater than for a not snoring child in spite of surgery (OR 3.7, 95% CI 2.4-5.7). 63 children had undergone surgery due to snoring by age 12. 14 of them never snored and 17 snored regularly at the age 12. The dental arch was narrower in the children snoring regularly at 4, 6 and 12 years compared to not snoring children. Cross-bites were more common among snoring children than among non-snoring children, at 4 and 6 as well as at 12.

Conclusion

The prevalence of regular snoring is about the same from 4 to 12 years independent of surgery, but the prevalence of OSA decreased considerably. The children snoring regularly generally have a narrower maxilla compared to children not snoring. Surgery in young children is necessary but “cures” the snoring only temporary.     

Comparison of clinical and histopathological evaluation of tonsils in pediatric and adult patients

The aim of this study was to determine clinical features that could predict the presence of tonsillar malignancy in children and adults. A retrospective review of the histopathologic reports of the children, who underwent tonsillectomy (753 cases) during the past 16 years (January 1991–December 2006) in a busy district general hospital, was undertaken. We compared the results to the pre-operative data of the patients, for risk factors of malignancy. Such proposed risk factors were tonsillar asymmetry, palpable firmness, visible lesions, neck adenopathy, history of malignancy, and systemic symptoms. The same data (history, risk factors and histopathologic results) were reviewed for an adult group (>16 years old, 1,027 cases) who underwent tonsillectomy during that period, and the results of the two groups were compared. In the pediatric group only one case was diagnosed as lymphoma (0.13%) and the rest as chronic inflammation (47%), reactive tonsil tissue (26%), lymphoid hyperplasia (19%) and actinomycosis (8%). In the lymphoma case, the diagnosis was suspected preoperatively by history and clinical manifestations. In the adult group, there were 21 cases of malignancy out of 1,027 cases (2.04%), again with one or more positive risk factors in the pre-surgery history. Based on our review, it is concluded that histopathology of tonsillectomy is not necessary in children unless there is clinical suspicion based on preoperative findings. A protocol based on proposed risk factors which may be predictive of possible malignancy can be used as a guide to intraoperative histology.     

Enzymatic study of tonsil tissue alkaline and acid phosphatase in children with recurrent tonsillitis and tonsil hypertrophy

Objective

Indications for tonsillectomy in recurrent tonsillitis are defined according to the number of episodes of acute bacterial infections in a year. However, little is known about the tonsil immune competence status in patients presenting with recurrent tonsillitis with either hypertrophied or atrophied tonsils, or in patients presenting with obstructive sleep apnoea. In this study we examined the tonsil immune status in children with 3-5 acute recurrent infections a year and in children with obstructive sleep apnoea by comparing the activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase.

Methods

Specific activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase was investigated in children who underwent tonsillectomy and adenoidectomy for recurrent infection (72 children) and for obstructive sleep apnoea (10 children). Tissue enzyme activities were measured using p-nitrophenylphosphate as a substrate. Tissue samples were examined by the haematoxylin-eosin histological technique. Statistical analyses were performed using SPSS v. 16 software.

Results

The tissue nonspecific alkaline phosphatase activity was similar in hypertrophied tonsils in the recurrent infection group and in the obstructive sleep apnoea group (3.437 ± 1.226 and 3.978 ± 0.762 U/mg of protein, respectively). The enzyme activity in both hypertrophied tonsil groups was significantly higher as compared to atrophied tonsils in the recurrent tonsillitis group, p = 0.021 and p = 0.006, respectively. The enzyme activity was significantly higher in the adenoids compared to the tonsils from all three groups. Contrary to this, no significant differences were noticed for tonsil and adenoid acid phosphatase activities among the groups.

Conclusion

Similar acid phosphatase activity in all three groups implies that all three groups have preserved antigen presenting cell activity. In patients with hypertrophied tonsils similar tissue nonspecific alkaline phosphatase activity suggests preserved B cell tonsil immune activity, regardless of the pathology. Patients with atrophied tonsils had significantly lower alkaline phosphatase activity, indicating relative tonsil B cell immune deficiency. Thus, different immunological status in patients presenting with hypertrophied vs. atrophied tonsils could point to a different underlying pathophysiologic mechanism of the disease.     

The Sluder method in the Netherlands and the incidence of postoperative haemorrhage in a pediatric hospital

Objective

Analysis of the method of tonsillectomy in use in the Netherlands and the incidence of postoperative haemorrhage in an academic tertiary pediatric referral hospital.

Study design and setting

(A) An explorative study of the Sluder tonsillectomy method in the Netherlands and (B) a retrospective case file review at the Sophia Children's Hospital in Rotterdam.

Methods

(A) A telephone and e-mail survey amongst 107 hospitals in the Netherlands. (B) A review of patients younger than 16 years who underwent a tonsillectomy or adenotonsillectomy between January 1, 1998, and February 22, 2008. This part of the study surveyed the intubated Sluder method and analyzed the incidence of primary and secondary haemorrhage in an academic tertiary pediatric referral hospital.

Results

(A) The Sluder method was commonly used in 102 (95.32%) hospitals; the traditional dissection technique was exclusively used only in five hospitals (4.67%). Of the 102 hospitals using the Sluder method, 67 (65.68%) report using only inhalation mask anaesthesia, while the remaining 35 use intubation. (B) Of 1797 patients studied, 40 patients experienced postoperative tonsillar haemorrhage (2.23%), with 35 (1.95%) patients primary haemorrhage of which 32 (1.78%) within 6 h after the surgery. Secondary haemorrhage occurred in five (0.28%) patients.

Conclusions

The Sluder method is still generally used in the majority of hospitals in the Netherlands today. Because of the low incidence of especially secondary haemorrhage and most of the primary haemorrhages occurring within 6 h after the surgery, this technique is ideally suited for day care tonsillectomy.     

PFAPA syndrome in children: A meta-analysis on surgical versus medical treatment

Objective

To compare the range of medical and surgical therapies for children with PFAPA syndrome.

Methods

A literature search was performed using Medline, Embase, Ovid and Cochrane databases for studies between 1987 and 2010 that compared PFAPA treatment in children (surgical versus medical). Random-effect meta-analytical techniques were conducted for the outcome measures.

Results

The use of antibiotics and cimetidine in PFAPA syndrome are ineffective. However, there is evidence that the use of steroids is effective in the resolution of symptoms. Tonsillectomy (+/− adenoidectomy) as a treatment of PFAPA was found to be an effective intervention for resolution of symptoms (P < 0.00001). Meta-analysis of surgery versus cimetidine and surgery versus antibiotics demonstrated that surgery is a significantly more effective treatment for PFAPA syndrome. A comparison of treatment with steroids or surgery did not show any statistically significant difference, confirming the effectiveness of both therapies for the resolution of PFAPA syndrome (P = 0.83).

Conclusions

The most effective non-surgical therapy is corticosteroids. However, they do not prevent future fever cycles. The results of this meta-analysis showed that tonsillectomy (+/− adenoidectomy) is the most effective intervention for long-term resolution of PFAPA syndrome symptoms.     

Polysomnography outcomes for partial intracapsular versus total tonsillectomy

Objective

To demonstrate similar improvement in pediatric sleep-disordered breathing (SDB) as determined by polysomnography (PSG) with microdebrider-assisted partial intracapsular tonsillectomy and adenoidectomy (PITA) versus Bovie electrocautery complete tonsillectomy and adenoidectomy (T&A).

Methods

In this retrospective cohort study, 30 children found to have SDB by PSG who have undergone either PITA (15 participants) or T&A (15 participants) as treatment were evaluated with standardized history and physical examination and unattended home overnight PSG.

Results

Median change in apnea-hypopnea index (AHI) was 1.7 (−4.9 to 29.8) for the PITA group and 2.3 (−10.9 to 64.1) for the T&A group, although there was substantially more variability in the T&A group. A mixed linear model evaluating the relation of surgical group with change in AHI demonstrated no significant differences in group means (F[1,13] = 0.31, P = .590) but the variances differed significantly (residual likelihood ratio chi-square = 5.24, df = 1, P = .022). Five of 15 (33%) PITA patients and 4 of 15 (27%) T&A patients had postoperative AHI scores of ≤5; this difference was not statistically significant (Fisher exact test P = 1.000). There was no significant interaction or substantial confounding effect of age, sex, race, preoperative tonsil size, preoperative AHI, or body mass index in the model relating surgery type to reduction of postoperative AHI to ≤5.

Conclusions

Our study demonstrates no clinically or statistically significant differences in PSG and clinical outcomes between PITA and T&A for treatment of pediatric SDB in otherwise healthy children.     

Difference of delayed post-tonsillectomy bleeding between children and adults

Objective

To analyze the characteristics of post-tonsillectomy bleeding and its management comparing with adults.

Methods

A retrospective chart review of 1489 patients who underwent tonsillectomy in our institution (June 2003–June 2006).

Results

Post-tonsillectomy bleeding rate was 3.1%, 2.5% and 10.8% in younger children (age ≤ 11 years), older children (12 ≤ age ≤ 15 years) and adults (age > 15 years), respectively. Although adults showed an unimodal peak time for onset of post-tonsillectomy bleeding, children showed a bimodal peak time. In the younger child group, all of the 28 bleeders had spontaneous hemostasis. However, in the older child group, there was no spontaneous hemostasis. Bleeding was controlled under local anesthesia in 3 patients and 2 patients required general anesthesia for bleeding control. In the adult group, spontaneous cessation of bleeding occurred in 25 patients (60.9%) and hemostasis under local or general anesthesia was performed in 16 (39.1%) patients.

Conclusions

Post-tonsillectomy bleeding occurred more frequently in adults than in children. Spontaneous hemostasis was more prevalent in children than in adults. Post-tonsillectomy bleeding in the younger child group was controlled with close observation alone.