Erkrankungen der Nase und der Nasennebenhöhlen im Kindesalter

Zusammenfassung

Erkrankungen der kindlichen Nase und Nasen­nebenhöhlen sowie angrenzender anatomischer Strukturen umfassen eine Vielfalt von Pathologien, vornehmlich aus dem entzündlichen Formenkreis. Angeborene Erkrankungen wie etwa Fehlbildungen und Formveränderungen des Nasengerüstes und des Nasenseptums sowie systemisch in der Schleimhaut auftretende Stoffwechselstörungen führen deutlich seltener zu einer HNO-ärztlichen Therapie.

Bei der Entstehung von Erkrankungen der kindlichen oberen Luftwege kommt der sich während des Wachstums stetig verändernden Anatomie der entsprechenden Bezirke, der immunologischen Funktion der Schleimhaut und genetischen Faktoren eine wesentliche Rolle zu. Epidemiologische Untersuchungen, evidenzbasierte Studien zur Beurteilung rhinochirurgischer Eingriffe und große, randomisierte Doppelblind-Studien zum Wirksamkeitsnachweis medikamentöser Therapieformen fehlen oftmals in der pädiatrischen Population.

Das breite Spektrum entzündlicher Erkrankungen der Nase und Nasennebenhöhlen wie etwa die akute und chronische Rhinosinusitis, die allergische Rhinitis und das Krankheitsbild der hyperplastischen Adenoide tragen im Allgemeinen zur Infektanfälligkeit des Kindes bei. Die pathologische Infektanfälligkeit ist bis dato nicht definiert. Die unkomplizierte akute Rhinosinusitis (ARS) stellt eine viral induzierte Erkrankung der Nasen- und Nasennebenhöhlenschleimhäute dar, die ­unabhängig von einer Therapie gut rückläufig ist. Eine antibiotische Behandlung ist bei komplizierten Episoden der ARS sinnvoll und bleibt Kindern mit Komplika­tionen oder Begleit­erkrankungen wie etwa dem Asthma bronchiale und der chronischen Bronchitis vorbehalten. Unter einer chronischen Rhinosinusitis (CRS) wird eine entzündliche Veränderung der Nasen- und Nasennebenhöhlenschleimhaut verstanden, die länger als 12 Wochen durch entsprechende Symptome geprägt ist. Eine Computertomografie der Nasennebenhöhlen zur Diagnostik der CRS ist bei einer medikamentös austherapierten chronischen Rhinosinusitis indiziert. Evidenzbasiert wird ein therapeutisches Stufenkonzept, welches medikamentöse und chirurgische Therapiestrategien in der Behandlung der CRS beschreibt, empfohlen. Die endoskopische Nasennebenhöhlenchirurgie wird bei Kindern als wirksam und sicher in der Behandlung der CRS eingestuft. Die Adenoiditis steht nach wie vor als kausale Ursache kindlicher Erkrankungen der oberen Luftwege im Vordergrund. Die Adenotomie heilt fast 60% der Kinder mit Symptomen der Rhinosinusitis.

Auch Komorbiditäten wie etwa das kindliche Asthma bronchiale spielen bei der Behandlung der CRS und der allergischen Rhinitis heute eine immer größer werdende Rolle, sodass oftmals eine therapeutische Mitbetreuung durch Pädiater sinnvoll ist. 40% der Kinder leiden heute in den westeuropäischen Ländern an einer allergischen Rhinitis, die bei ausgeprägter Verlegung der oberen Luftwege zu einer Wachstumsstörung des Gesichtsschädels und zu weiteren Komorbiditäten führen kann. Obwohl der Nachweis einer möglichen Prävention von Asthma bronchiale (Etagenwechsel) und sekundären Sensibilisierungen auf inhalative Allergene durch eine spezifische Immuntherapie (SIT) weiterhin Gegenstand von Untersuchungen ist, wird die SIT, wenn möglich, zur Behandlung der allergischen Rhinitis empfohlen.

Rhinochirurgische Therapieansätze sind häufig als Erfahrungsberichte wiedergegeben und entbehren einem heute geforderten Standard nach prospektiv, randomisierten Langzeitstudien. Aus diesem Grund findet sich oftmals kein Konsens zu einer einheitlichen Therapie in der Literatur, und bestehende Literatur­daten müssen zurückhaltend bewertet werden.

Abstract

Diseases of the Nose and Paranasal Sinuses in Childhood

Diseases of the pediatric nose and paranasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist.

The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population.

The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the „common cold“ in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy.

Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Schlüsselwörter

Nase - Nasennebenhöhlen - Kindheit - Erkrankungen - Rhinosinusitis

Key words

nose - paranasal sinuses - childhood - diseases - rhinosinusitis

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