Хронический тонзиллит

[Artemij Okhotin]

Уважаемые доктора!
Кто посоветует, где вооружиться реальной информацией про хронический тонзиллит и так называемые "сопряженные с ним заболевания".
Единственное, что нашел -- статью на РМЖ [Ссылки доступны только зарегистрированным пользователям ] где все ДОКАЗАНО, но не указано НИ ОДНОЙ ССЫЛКИ. Есть ли работы, реально доказывающие связь хронического тонзиллита с "сопряженными заболеваниями"?
В Medline тоже ничего не нашел. Складывается впечатление, что это тайна за семью печатями, доступная только отоларингологам

[Sana]

Вот Вам ссылки - [Ссылки доступны только зарегистрированным пользователям ]

[Ссылки доступны только зарегистрированным пользователям ]

[Ссылки доступны только зарегистрированным пользователям ]

[Ссылки доступны только зарегистрированным пользователям ] - это о препарате, лечащем тонзиллит.

[Dr.Vad]

В обзоре Johnson BC, Alvi A.

Cost-effective workup for tonsillitis. Testing, treatment, and potential complications.

Postgrad Med. 2003 Mar;113(3):115-8

указывается "A possible complication of infection with group A streptococci is rheumatic fever, a multisystem inflammatory disorder usually seen in children. Rheumatic fever is characterized by cardiac manifestations, including pericarditis, myocarditis, and endocarditis. Arthralgia, arthritis, skin lesions, and central nervous system involvement (chorea) may be seen. Fortunately, use of antimicrobial agents has made rheumatic fever a rare entity. "

Кроме этого существуют предположения

Pediatr Dermatol. 2003 Jan-Feb;20(1):11-5.

Treatment of psoriasis in children: is there a role for antibiotic therapy and tonsillectomy?

Wilson JK, Al-Suwaidan SN, Krowchuk D, Feldman SR.

Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.

Numerous studies implicate subclinical or recurrent streptococcal infection as a trigger or maintenance factor in the pathogenesis of psoriasis in children. The purpose of this article is to review the efficacy of antibiotic therapy and tonsillectomy as treatments for childhood psoriasis. Clinical trials assessing the efficacy of antibiotics or tonsillectomy as treatments for childhood psoriasis were identified with a search of the medical literature and the results were compared. Only one controlled clinical trial was identified and it did not find a significant effect of antibiotic treatment on psoriasis. In other studies, the percentage of psoriasis patients who experienced disease clearance with antibiotic therapy ranged from 0% to 55%, with no patients experiencing disease worsening during treatment. No controlled trials of tonsillectomy for psoriasis were identified. The percentage of patients who experienced disease clearance after tonsillectomy in uncontrolled trials ranged from 32% to 53% and a similar percentage reported significant improvement in their psoriasis, with a maximum of 7% noting worsening of the disease after the operation. The available evidence does not demonstrate the efficacy of either antibiotic therapy or tonsillectomy in the treatment of childhood psoriasis. Because these treatments are relatively benign compared to other treatments for severe psoriasis, the use of antibiotic therapy or tonsillectomy may still be worth considering, especially for those patients with recurrent streptococcal infections that seem to trigger or maintain their skin disease.


England RJ, Strachan DR, Knight LC.
Streptococcal tonsillitis and its association with psoriasis: a review.
Clin Otolaryngol. 1997 Dec;22(6):532-5.


и отдельные случаи


Int Urol Nephrol. 1999;31(2):145-8.

Acute post streptococcal interstitial nephritis in an adult and review of the literature.

Dharmarajan TS, Yoo J, Russell RO, Boateng YA.

Division of Nephrology, Our Lady of Mercy Medical Center, University Affiliate of New York Medical College, Bronx, USA.

While glomerular lesions are a recognized sequel to infection with group A beta haemolytic streptococci, literature on primary tubular lesions, as remote effects of streptococcal infection, is scanty. A case of interstitial nephritis in a 29-year-old woman following streptococcal sore throat is described. This adult admitted with tonsillitis developed acute renal failure from acute interstitial nephritis and subsequently had full recovery of renal function. Acute interstitial nephritis should be included in the differential diagnosis of patients with streptococcal infections who develop acute renal failure.


J Neurol Sci. 1998 Sep 18;160(1):64-6.

Fisher's syndrome and group A streptococcal infection.

Yuki N, Hirata K.

Department of Neurology, Dokkyo University School of Medicine, Shimotsuga, Tochigi, Japan.

Group A beta-hemolytic streptococcus causes immune-mediated disorders such as acute rheumatic fever and acute glomerulonephritis. We describe a second patient with Fisher's syndrome (FS) from whom beta-hemolytic streptococcus was isolated. We performed a study of the antecedent pharyngeal symptoms in FS and Guillain-Barre syndrome. Sore throat was statistically more frequent in FS (18/24 cases, 75%) than in Guillain-Barre syndrome (29/58 cases, 50%). In a series, however, the association of FS with group A streptococcal infection was not shown. Some patients may develop FS after group A streptococcal infection, but the bacterium is not a major antecedent agent in FS.



Int J Pediatr Otorhinolaryngol. 1998 Sep 15;45(1):51-7.

Lemierre syndrome: a complication of acute pharyngitis.

Williams A, Nagy M, Wingate J, Bailey L, Wax M.

Department of Otolaryngology at the State University of New York, Buffalo, USA.

Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.

[Artemij Okhotin]

Спасибо, Dr.Vad. Но то, что Вы пишете относися к острому фарингиту, вызванному гемолитическими стрептококками группы A. А меня интересует именно хронический тонзиллит.
Вот в ссылках, которые приводит Sana речь идет даже о системной склеродермии и СКВ, не говоря уж о т.н. кардиотонзиллярном синдроме. Но тем это никак не обосновано. Те же обоснования, которые мне удалось найти, выглядят так, что плакать хочется. Вот пример:

О.О. Куприянова, О.В. Кожевникова, Н.Р. Белова, Л.П. Мещеряков
НАРУШЕНИЯ РИТМА СЕРДЦА У ДЕТЕЙ С ХРОНИЧЕСКИМ ТОНЗИЛЛИТОМ
Научный центр здоровья детей РАМН,
Москва

Цель работы: изучить нарушения ритма сердца (НРС) у детей c хроническим тонзиллитом(ХТ).

Материалы и методы: Обследовано 66 детей c функциональной кардиопатией в возрасте от 4 до 15 лет, у которых нарушения ритма сердца были этиопатогенетически обусловлены ХТ. Всем детям проводилось 24-часовое мониторирование ЭКГ (СМ ЭКГ), эхокардиография.

Результаты исследования: отмечены в 77% случаев частые суправентрикулярные и желудочковые экстрасистолы, а также парасистолия. У этих детей чаще выявлялись нарушения атриовентрикулярной проводимости: от транзиторного ее замедления до атриовентрикулярной блокады II степени. У 83.3% детей определялись нарушения процессов реполяризации желудочков. Аритмия у детей с хроническим тонзиллитом в 88% случаев сочеталась с наличием малых аномалий сердца.

Заключение: у детей с экстракардиальной причиной аритмии в виде хронического тонзиллита отмечены разнообразные нарушения ритма сердца и проводимости.


Так, все-таки, миф это или реальность?

[Dr.Vad]

Уважаемый Артемий!

Мне кажется, что в последние годы за рубежом вместо хронич. употребим рецидивир. тонзиллит:

что-то из древностей:

Arch Otolaryngol. 1983 Jan;109(1):30-3.

Cardiopulmonary changes secondary to chronic adenotonsillitis.

Talaat AM, Nahhas MM.

Thirty children with lower respiratory tract infection of varying degrees secondary to chronic tonsillitis and/or enlarged adenoids were studied clinically and roentgenographically. Symptoms and signs of alveolar hypoventilation and signs of cor pulmonale were present in two of them. These symptoms and signs improved markedly after adenoidectomy and tonsillectomy. The relationship of the lung changes to the incidence of cor pulmonale is discussed. The development of recurrent attacks of severe lower respiratory tract infection secondary to diseased tonsils and adenoids is believed to play an important role in the pathogenesis of cor pulmonale in children with upper respiratory tract obstruction due to chronically enlarged tonsils and adenoids.

А вот более новые:

Lancet. 1990 Feb 3;335(8684):249-53.

Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children.

Stradling JR, Thomas G, Warley AR, Williams P, Freeland A.

Osler Chest Unit, Churchill Hospital, Oxford, UK.

61 snoring children selected for adenotonsillectomy, mainly for recurrent tonsillitis, were compared with a matched group of 31 healthy children for symptoms of sleep apnoea, extent of sleep hypoxaemia, and amount of sleep disturbance. The studies were repeated six months postoperatively, and after six months in the healthy children. Preoperatively, 61% of the children had degrees of sleep hypoxaemia above normal and 65% had abnormally disturbed sleep. A questionnaire administered to the parents about their children showed abnormal patterns of answers about sleep problems daytime sleepiness, hyperactivity, aggression, learning difficulties, restless sleep, and odd sleeping positions. After adenotonsillectomy, the abnormal hypoxaemia, excessive sleep disturbance, and multiple symptoms almost resolved; a growth spurt also occurred.


Clin Otolaryngol. 2001 Feb;26(1):43-6.

A comparison of sleep quality in normal children and children awaiting (adeno)tonsillectomy for recurrent tonsillitis.

Capper R, Canter RJ.

Department of Otolaryngology/Head and Neck Surgery, University Hospital, Queen's Medical Centre, Nottingham, UK.
Poor quality sleep and sleep-related hypoxia have been described in children awaiting (adeno)tonsillectomy even in the absence of a history which would suggest such problems. However, restless sleep has also been commonly reported in children from a normal population. It has not been shown whether an increasing frequency of tonsillitis is associated with deterioration in sleep quality. This study directly compares sleep quality in three groups of children: (1) a normal population; (2) children from a normal population who have tonsillitis but are not awaiting tonsillectomy; and (3) children awaiting tonsillectomy for recurrent tonsillitis. A questionnaire was completed by the parents and the answers compared using the chi2 and Spearman's rank correlation tests. The results show that children awaiting tonsillectomy have poorer sleep quality than their normal peers. However, there is no dose-response effect between deteriorating sleep quality and increasing frequency of tonsillitis.


Int J Pediatr Otorhinolaryngol. 2003 Aug;67(8):837-40.

PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections--an uncommon, but important indication for tonsillectomy.

Heubi C, Shott SR.

Department of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, also know as "PANDAS," is well described in the neurologic and psychiatric literature. PANDAS is associated with obsessive compulsive disorders (OCD) and tic disorders. The streptococcal infections may trigger an autoimmune reaction that exacerbates these conditions. Recurrent streptococcal tonsillitis is one of the recurrent infections associated with PANDAS. This paper reviews the case reports of two brothers, one with OCD and the other with a tic disorder, both of whom improved significantly after undergoing adenotonsillectomy for treatment of their recurrent tonsillitis. A review of the pathophysiology and current understanding of PANDAS is presented.


Мне кажется, что опасность хронического процесса как раз и определяется частотой развития рецидивов или общего числа обострений в течение года, когда каждое обострение и может служить толчком для стрептококк-инд. соматического поражения. На мой взгляд наиболее полно по проблеме можно прочесть в оригинале

Pediatr Clin North Am. 2003 Apr;50(2):445-58.

Infectious indications for tonsillectomy.

Discolo CM, Darrow DH, Koltai PJ.

Department of Otolaryngology and Communicative Disorders, Desk A71, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

...Recurrent throat infections of either bacterial or viral etiology can cause significant morbidity and decreased quality of life, and potentially lead to life-threatening complications...

который, по-моему, доступен на сайте [Ссылки доступны только зарегистрированным пользователям ] в течение 10-дн. беспл. регистрации.