[Frequency of secondary tonsillectomy in Germany]. / Häufigkeit sekundärer Tonsillektomien in Deutschland.

BACKGROUND: 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). OBJECTIVE: 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. MATERIALS AND METHODS: STE was identified using the operation and procedure key (Operationen- und Prozedurenschlüssel, OPS) code 5­281.4, 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 5­281.5, 5­281.0, and 5.282.0. RESULTS: 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. CONCLUSION: 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.

[Sore throat as indication for tonsillectomy before and after implementation of the German guideline for tonsillitis : Longitudinal study covering 115.839 procedures]. / Halsschmerzen als Operationsindikation vor und nach Publikation der Tonsillitis-Leitlinie : Longitudinalstudie mit 115.839 Tonsillektomiefällen.

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; 5­282.0). 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 (<10 years; -65.7%). Every second patients had received conservative treatment at the most in only one preoperative quarter. CONCLUSIONS: 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.

Is the number of tonsillectomies and tonsillotomies a relevant issue?

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

[Is the number of tonsillectomies and tonsillotomies a relevant issue? German version]. / Sind Tonsillektomie und Tonsillotomie "mengenanfällige" Eingriffe?

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

[Tonsil surgery in the federal states of Germany: similarities and differences. German version]. / Tonsillenchirurgie in den Bundesländern: Unterschiede und Gemeinsamkeiten.

BACKGROUND: 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. OBJECTIVE: To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: 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.

[Hospitalization of children after ENT surgery in Germany]. / Hospitalisierung von Kindern nach HNO-Eingriffen in Deutschland.

BACKGROUND: 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. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: There is currently no uniform hospitalization strategy for postoperative care of children who undergo typical otorhinolaryngologic interventions in Germany.

Tonsil surgery in the federal states of Germany: similarities and differences.

BACKGROUND: 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. OBJECTIVE: To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Extranasopharyngeal angiofibroma revisited.

BACKGROUND: Angiofibromas in the head and neck region usually arise in the nasopharynx, but may also occur elsewhere. This study aims at evaluating the incidence and clinical features of extranasopharyngeal angiofibroma (ENA). MATERIAL AND METHODS: Systematic review of the literature (Medline® and Google™ ) up to 31 December 2015. RESULTS: 174 cases of ENA were retrieved from a total of 170 publications. In contrast to former publications and previous understanding, the nasal septum was by far the most common site of the disease. Four patients had a congenital lesion, the oldest patient was 87 years old (mean: 28.7 years; median: 23 years). Male gender was predominantly affected, but the sex ratio was more balanced (2.13:1) than in previous reports in the literature until 12/2015. The majority of patients presented with nasal obstruction, either in combination with epistaxis (25.8%) or other symptoms (12.6%). Symptoms had developed within 13.1 months on average (median: 4 months). Brisk bleeding resulted in 11 of 43 biopsy procedures. Surgical resection as first-line therapy was performed in 170 patients. A tumour regrowth within 12 months was registered in four patients. CONCLUSION: The increasing awareness of ENA and the willingness to publish case reports-not only in Medline-listed journals-resulted in a significant increase of published case reports lately. Although extremely rare, ENAs have to be taken into account in the differential diagnosis of unclear masses, particularly in adult patients presenting with a rapidly developing nasal obstruction resulting from a nasal septum tumour. Female gender or normal vascularity does not exclude the diagnosis. Transnasal resection is sufficient in most cases, and recurrences are rare. Pathologists as well as clinicians should consider ENA in their differential diagnosis of any mass of the upper airway.

[Tonsil surgery: impact of the mouth gag on pharyngeal diameter]. / Tonsillenchirurgie: Einfluss des Tonsillenspatels auf den Pharynxdurchmesser.

BACKGROUND: 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. OBJECTIVE: Using the archived photo documentation, this study aimed to evaluate the impact of two different positions of the mouth gag on the oropharyngeal airway. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.