A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy

Formula for predicting OSA and the Apnea-Hypopnea Index in Koreans with suspected OSA using clinical, anthropometric, and cephalometric variables

PURPOSE

This study developed formulas to predict obstructive sleep apnea (OSA) and the Apnea-Hypopnea Index (AHI) in Korean patients with suspected OSA using clinical, anthropometric, and cephalometric variables.

METHODS

We evaluated relevant variables in 285 subjects with suspected OSA. These included demographic characteristics, sleep-related symptoms, medical history, clinical scales, anthropometric measurements including facial surface measurements, and cephalometric measurements. All participants underwent full-night laboratory polysomnography. The prediction formula for the probability of OSA was created by logistic regression analysis and confirmed by the bootstrap resampling technique. The formula for predicting the AHI was developed using multiple linear regression analysis.

RESULTS

The probability of having OSA was as follows: p = 1 / (1 + exponential (exp)^-f ), where f = -16.508 + 1.445 × loudness of snoring 4 + 0.485 × loudness of snoring 3 + 0.078 × waist circumference + 0.209 × subnasale-to-stomion distance + 0.183 × thickness of the uvula (UTH) supine + 0.041 × age. The AHI prediction formula was as follows: -112.606 + 3.516 × body mass index + 0.683 × mandibular plane-hyoid supine + 10.915 × loudness of snoring 4 + 6.933 × loudness of snoring 3 + 1.297 × UTH supine + 0.272 × age.

CONCLUSION

This is the first study to establish formulas to predict OSA and the AHI in Koreans with suspected OSA using cephalometric and other variables. These results will contribute to prioritizing the order in which patients with suspected OSA are referred for polysomnography.

Very Severe Obstructive Sleep Apnea in Children: Outcomes of Adenotonsillectomy and Risk Factors for Persistence

Objectives

(1) To describe the clinical, demographic and polysomnographic (PSG) characteristics of children with very severe obstructive sleep apnea (OSA) without significant comorbidities; (2) to assess the outcomes following tonsillectomy and adenoidectomy (T&A); and (3) to determine predictors of persistence of OSA after T&A.

Study Design

Case series with chart review.

Setting

Tertiary-level freestanding children’s hospital.

Subjects and Methods

Seventy-four children aged 2 to 12 years who underwent T&A for very severe OSA (obstructive apnea-hypopnea index [AHI] >30) were included. Children with significant comorbidities were excluded. PSG variables were compared pre- and post-T&A using statistical tests. Factors affecting OSA resolution and persistence were studied.

Results

The mean (95% confidence interval) age was 4.3 (3.8-4.7) years with the majority black or Hispanic (64/74, 86%). The mean decrease in AHI after T&A was 49 (43-58) ( P < .001). Complete resolution of OSA, defined by an AHI <1, or an AHI <5 was seen in 32% (24/74) and 80% (59/74), respectively. Total sleep time (TST) greater than 5 minutes with end-tidal CO2 >50 mm Hg was strongly associated with persistent OSA. The decrease in AHI post-T&A was best predicted by higher preoperative oxygen saturation (SpO2) nadir and lower TST with SpO2 <90% ( R2 = 0.24, P < .001).

Conclusions

T&A is associated with a significant improvement but not resolution of very severe OSA. The severity of baseline hypercapnia and hypoxemia may best predict persistent OSA after T&A. The study supports obtaining routine post-T&A PSG in children with very severe OSA.

Congruence between polysomnography obstructive sleep apnea and the pediatric sleep questionnaire: fatigue and health-related quality of life in juvenile idiopathic arthritis

PURPOSE

To examine the congruence between polysomnography obstructive apnea hypopnea index (OAHI) and parent-reported obstructive sleep apnea (OSA) symptoms in 6- to 11-year-old children with juvenile idiopathic arthritis (JIA) and controls; and to compare fatigue and quality of life in JIA and control children based on OAHI and OSA symptoms.

METHODS

Sixty-eight children with JIA and 75 controls and a parent participated. Children underwent one night of polysomnography in a sleep laboratory. Parents completed the sleep-related breathing disorders scale-pediatric sleep questionnaire (PSQ), and both children and parents completed the Pediatric Quality of Life Generic Core Scale and the Multidimensional Fatigue Scale.

RESULTS

In JIA, 86% who met the OAHI clinical criteria for OSA (≥1.5) were above the PSQ OSA symptom cut-off score with a sensitivity of 0.86 and a specificity of 0.28. In the control group, 63% who met the OAHI clinical criteria for OSA were above the PSQ OSA symptom cut-off score, with a sensitivity of 0.63 and a specificity of 0.42. All children above both the clinical criteria for OAHI and OSA symptom cut-off score had the most impaired quality of life and greater fatigue compared to those below both the clinical criteria for OAHI and the OSA symptom cut-off score.

CONCLUSION

Children who meet clinical criteria for OSA and also scored high on a parent-reported screening tool for OSA symptoms had the most impaired quality of life and more fatigue. The PSQ has potential to identify children at risk for OSA.

Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3-6 year old children undergoing adenotonsillectomy

INTRODUCTION

Adenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3-6 years with caregiver-reported symptoms.

METHODS

Children 3-6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.

RESULTS

The cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = -0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.

CONCLUSION

Subjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3-6 years of age undergoing adenotonsillectomy.

Adenoidectomy: Long-term Follow-Up

OBJECTIVE: To assess the long-term (3-5 years) success of adenoidectomy and reasons for unsatisfactory results.

STUDY DESIGN AND SETTING: The parents of all children who underwent adenoidectomy alone at a major tertiary center from 1998 to 2000 were asked to complete a questionnaire assessing their child's well-being and symptomatology 3-5 years after surgery; some were invited for follow-up. Symptom improvement, persistent symptoms, and adenoid regrowth were evaluated.

RESULTS: Among the 206 parents who complied, 74%-87% reported improvement in all main symptoms: nasal obstruction, snoring, chronic rhinorrhea, hyponasal speech, and obstructive sleep disorder. At follow-up (n = 36), the symptomatic patients had significantly more anatomic nasal abnormalities ( P = 0.01) and a higher rate of significant adenoid enlargement ( P = 0.08), 3 patients (19%) vs none (0%).

CONCLUSIONS AND SIGNIFICANCE: Adenoidectomy alone is satisfactory treatment for nasal obstruction and obstructive sleep apnea in selected children. Though some adenoid regrowth is not rare, clinically significant adenoid regrowth is infrequent. Persistent or recurrent symptoms are attributable mainly to nasal pathology.

Assessment of common otolaryngological diseases among children in rural primary schools in south eastern Nigeria

OBJECTIVES

Despite a global improvement in health care delivery, rural areas in developing countries still have poor access to specialist care. This study aims to assess the occurrences of ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria.

METHODS

Two rural primary schools were selected randomly from one of the rural regions of South Eastern State of Nigeria. All the pupils of the schools who gave consent were recruited. A structured study proforma investigating the pupils' biodata, otolaryngological symptoms, ear, nose and throat examination findings, was used to evaluate each pupil in the presence of the teachers.

RESULTS

A total of 246 children participated in the study. 145(58.9%) were males while 101(41.1%) were females with a mean age of 8.5 ± 2.4 years. The commonest symptoms reported were nasal discharge (20%) followed by nasal obstruction (11.1%), itching of the ears (11.1%) and sneezing bouts (10%), while 3.7% had subjective hearing impairment. The commonest ENT finding was cerumen auris (43%) and this was observed in 43.4% of males and 42.4% of females, 11% had abnormal tympanic membranes and 20% had grades 3/4 tonsils(Brodsky grading).

CONCLUSION

ENT disorders are still common in children in the rural areas of developing countries. To avoid the morbidity associated with these preventable and easily manageable disorders, community health workers should be trained to manage common ENT disorders and mobile clinics with scheduled visits made available in areas where ENT services remain inaccessible.

Outcome of Adenotonsillectomy for Obstructive Sleep Apnea in Obese and Normal-Weight Children

OBJECTIVES: 1) To evaluate the relative severity of obstructive sleep apnea (OSA) in obese and normal-weight children; 2) to compare changes in respiratory parameters after adenotonsillectomy in obese and normal-weight children.

STUDY DESIGN AND SETTING: Prospective controlled trial that included children aged 3 to 18 years. All study participants underwent pre- and postoperative polysomnography.

RESULTS: The study population included 33 obese children and 39 normal-weight controls. Preoperatively, the median obstructive apnea-hypopnea index (AHI) was 23.4 (range 3.7-135.1) for obese and 17.1 (range 3.9-36.5) for controls ( P < 0.001). Postoperatively, the AHI was 3.1 (range 0-33.1) for obese and 1.9 (range 0.1-7.0) for controls ( P < 0.01). Twenty-five obese children (76%) and 11 controls (28%) had persistent OSA.

CONCLUSION AND SIGNIFICANCE: AHI scores are higher in obese than in normal-weight children with OSA. Both groups show a dramatic improvement in AHI after adenotonsillectomy, but persistent OSA is more common in obese children.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE

Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index.

METHODS

We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room.

RESULTS

Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224).

CONCLUSION

Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

The Effect of Tonsillectomy and Adenoidectomy on Right Ventricle Function and Pulmonary Artery Pressure by Using Doppler Echocardiography in Children

Objectives

The purpose of the present study is to emphasize the efficacy of the myocardial performance index and tricuspid annular plane systolic excursion (TAPSE) in the determination of impaired cardiac functions and recovery period following the treatment in children with adenoid and/or tonsillar hypertrophy.

Methods

Fifty-three healthy children after routine laboratory, imaging and clinical examinations, with adenoid and/or tonsillar hypertrophy were evaluated before and 3 months after adenotonsillectomy for cardiac functions using M mode and Doppler echocardiography.

Results

The mean age of cases was 6.4±3.0 years, 34 (65%) were male, and 19 (35%) were female. Pulmonary hypertension was observed to be mild in 3 patients and moderate in 1 patient preoperatively. When the preoperative and postoperative echocardiographic measurements of the patients were compared, the tricuspid valve E wave velocity, the E/A ratio (E, early diastolic flow rate; A, late diastolic flow rate), and the TAPSE values were determined to be significantly higher postoperatively (P<0.05). The tricuspid valve deceleration time, the isovolumetric relaxation time and the systolic pulmonary artery pressure were found to be significantly lower compared to the preoperative values (P<0.05).

Conclusion

Adenoidectomy and/or tonsillectomy may prevent cardiac dysfunctions that can develop in the later periods due to adenoid and/or tonsil hypertrophy in children, before the appearance of the clinical findings of cardiac failure.

Mean Platelet Volume, Vitamin D and C Reactive Protein Levels in Normal Weight Children with Primary Snoring and Obstructive Sleep Apnea Syndrome

INTRODUCTION

Studies on Mean Platelet Volume (MPV) in children with Sleep Disordered Breathing (SDB) report conflicting results and the hypothesis of an intermittent hypoxemia leading to a systemic inflammation is reaching consensus. Vitamin D exerts anti-inflammatory properties and its deficiency has been supposed to play a role in sleep disorders. Emerging interest is rising about Primary Snoring (PS) since it is reasonable that also undetectable alteration of hypoxia might predispose to an increased production of inflammatory mediators. In this perspective, in a group of children affected by SDB, our aim was to investigate MPV, vitamin D and C Reactive Protein (CRP) levels, which had been previously evaluated separately in different studies focused only on Obstructive Sleep Apnea Syndrome (OSAS).

MATERIALS AND METHODS

We enrolled 137 children: 70 healthy controls (HC), 67 affected by SDB undergoing a polysomnographic evaluation, 22 with a diagnosis of PS and 45 with a diagnosis of OSAS. All patients underwent routine biochemical evaluations including blood cell counts, CRP and vitamin D.

RESULTS

Children affected by SDB had a mean age of 8.49±2.19 and were prevalently males (23 females, 34%; 44 males, 66%). MPV levels were higher in OSAS and PS when compared to HC; platelet count (PLT) and CRP levels were higher while Vitamin D levels were lower in children with SDB when compared to HC. MPV levels were correlated with PLT (r = -0.54; p<0.001), vitamin D (r = -0.39; p<0.001) and CRP (r = 0.21; p<0.01). A multiple regression was run to predict MPV levels from vitamin D, CRP and PLT and these variables significantly predicted MPV (F = 17.42, p<0.0001; adjusted R2 = 0.37). Only platelet count and vitamin D added statistically significantly to the prediction (p<0.05).

CONCLUSION

The present study provides evidence of higher MPV and lower vitamin D levels in children with PS as well as in children with OSAS, and supports the underlying inflammation, hence, highlighting the importance of an early diagnosis of this previously considered benign form of SDB.

Risk factors for residual obstructive sleep apnea after adenotonsillectomy in children

OBJECTIVES/HYPOTHESIS

To determine the prevalence of residual obstructive sleep apnea (OSA) in children who had adenotonsillectomy (AT) and to identify the risk factors for residual OSA after AT.

STUDY DESIGN

Retrospective chart review.

METHODS

Children with OSA who had AT at a tertiary care children's hospital were reviewed. Data pertaining to demographics, past medical history, body mass index, tonsil and adenoid size, and polysomnography were obtained. Residual OSA was defined as apnea hypopnea index (AHI) greater than 2. The rate of residual OSA and risk factors for residual OSA were assessed.

RESULTS

One hundred sixty-nine children with OSA underwent polysomnography before and after AT. The prevalence of residual OSA was 38%. The prevalence of residual OSA in obese patients (49%) was higher than that of nonobese patients (27%) (P = .02). Patients with neurological/developmental/craniofacial abnormalities had higher prevalence of residual OSA (44%) than patients without comorbidities (33%) (P < .05). The prevalence of residual OSA in patients with severe OSA (42%) was higher than patients with moderate (29%) or mild OSA (0%) (P = .03). Teenage patients (67%) had a higher prevalence of residual OSA than toddlers (27%), preschooler (33%), and middle childhood groups (29%) (P = .03).

CONCLUSIONS

The majority of children had improvement in OSA after AT. The choice of AHI threshold used to define residual OSA influenced the prevalence of residual OSA. Teenagers and children with obesity, comorbidities including neurological/developmental/craniofacial abnormalities alone or in combination with asthma, or severe OSA have a high risk of residual OSA.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:2624-2629, 2016.

Clinical risk assessment model for pediatric obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To develop a clinical risk prediction model that identifies children with obstructive sleep apnea (OSA) in a clinical setting by examining the symptoms, physical status, and OSA-18 questionnaire results.

DESIGN

Single institutional, cross-sectional study.

METHODS

Children aged 2 to 18 years with symptoms of OSA were enrolled. Pediatric OSA was diagnosed through full-night polysomnography. Clinical data, namely demographics, symptoms, OSA-18 survey results, tonsil and adenoid sizes, and the weight of each child, were examined for constructing a simple point-based clinical model for OSA prediction. Variables for the risk model were selected using multivariable logistic regression analyses.

RESULTS

Of the 310 participants (mean age, 7.6 ± 3.7 years; boys, 67%), 170 (55%) experienced OSA. Modeling variables were determined using several univariate logistic regression analyses, followed by multivariable logistic regression analyses. A point-based clinical model incorporating the age, tonsil size (5 points maximum), adenoid size (5 and 20 points for age > 6 years and < 6 years, respectively), obesity (5 points for age > 6 years), and breathing pauses (5 points) was developed (area under the curve = 0.832). Moreover, the optimal cutoff points for predicting the apnea-hypopnea index of > 1 and > 5 were 10 (sensitivity, 72.9%; specificity, 65.0%) and 12 (sensitivity, 77.5%; specificity, 56.9%), respectively. Internal validation using the bootstrap method revealed no apparent overfitting problem.

CONCLUSION

A novel clinical prediction model was developed for determining the risk of pediatric OSA; the model can be useful in identifying high-risk patients among those with sleep disturbances.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2403-2409, 2016.

Changes in body composition and growth pattern after adenotonsillectomy in prepubertal children

OBJECTIVE

Adenotonsillar hypertrophy and chronic tonsillitis are associated with growth interruption during childhood, while adenotonsillectomy has been associated with growth improvement and increased body mass index (BMI). However, no reported study has investigated the effect of adenotonsillectomy on the proportion of body muscle and fat mass. The aim of this prospective study was to evaluate the effect of adenoidectomy and adenotonsillectomy on body muscle and fat composition in prepubertal children.

METHODS

Thirty prepubertal children (22 boys, 8 girls; 3-9 years of age) were followed up for 6 months after adenoidectomy or adenotonsillectomy. Twenty-eight age-matched healthy children (12 boys, 16 girls) were followed for the same period, as controls. Data on dietary habits and physical activity were obtained from parent-completed questionnaires at baseline and 6 months. Height and weight z-scores, the amount and percentage of body fat and muscle mass, BMI z-scores, relative BMI and basal metabolic rate were evaluated before and 6 months after surgery with bioelectrical impedance analysis.

RESULTS

After 6 months, body muscle mass and basal metabolic rate scores were significantly higher than at baseline in both groups (P<0.05). The rate of increase was not different between the groups. In the study group, the relative BMI scores improved significantly (P<0.05). Increases in body fat mass, body fat percentage, height z-scores, weight z-scores and BMI z-scores were not significantly different between the groups at 6 months (P>0.05). The number of overweight and obese children did not change significantly in either group (P<0.05).

CONCLUSIONS

Adenotonsillectomy led to improvement in relative BMI and promoted healthy weight gain without increased body fat percentage in prepubertal children.

Clinical manifestations of pediatric obstructive sleep apnea syndrome: Clinical utility of the Chinese-version Obstructive Sleep Apnea Questionaire-18

AIMS

Childhood obstructive sleep apnea syndrome (OSA) affects not only the children's physical health, but also their mental development, behavioral problems and learning difficulties. Therefore, an early diagnosis is important. However, the assessment tools of polysomnography are demanding. The Obstructive Sleep Apnea Questionnaire-18 (OSA-18) is designed to screen OSA and has good reliability and validity. The goal of this study was to validate the Chinese version of the OSA-18, to analyze the frequency of symptoms and find the most common symptoms of OSA in Taiwanese children.

METHODS

We validated the OSA-18 in an ethnic Chinese group and compared the treatment outcomes to show the sensitivity of the questionnaire. The caregivers completed the questionnaire twice at an interval of 4 weeks to test reliability. In the validation study, we included 88 OSA children. The OSA-18 and follow-up polysomnography were performed before and 6 months after adenotonsillectomy.

RESULTS

Results showed the excellent test-retest reliability (r = 0.84**) of the OSA-18. There was a statistically significant correlation between the OSA-18 and, respectively, the Apnea-Hypopnea Index (r = 0.29*), and the Hypopnea Index (r = 0.29*). Quality of life showed a significant correlation with the Apnea Index (r = 0.43**), central apnea count (r = 0.50***), and mixed apnea count (r = 0.36*). The cut-off point of the OSA-18 total scores for detecting pediatric OSA in children aged 6-12 years was 66. The common symptoms of pediatric OSA were poor attention span, loud snoring, caregiver worried about child's health, difficulty awakening, and mouth breathing.

CONCLUSIONS

Our results show that the Chinese version of the OSA-18 is a reliable and valid instrument. The questionnaire also showed improvement in the quality of life of OSA children post-adenotonsillectomy.

The immediate effect of adenotonsillectomy on Eustachian tube function in children

OBJECTIVES

The aim of this study was to evaluate the effect of adenotonsillectomy on immediate Eustachian tube (E-tube) function in children with adenotonsillar hypertrophy.

METHODS

All children who were scheduled to undergo adenotonsillectomy were assessed. Physical examinations were performed on the preoperative day, and on postoperative days 1 and 2. Exams included visual inspection of the tympanic membrane and tympanometry including measurement of middle ear pressure (MEP) (daPa). The children were divided into four types (AA, CA, CC, and BB types) based on the tympanometric results of postoperative days 1 and 2.

RESULTS

A total of 50 ears from 25 children (mean age±standard deviation [SD]=8.6±3.2; male/female=10/15; mean body mass index±SD [kg/m(2)]=18.5±3.7) were included. The rates of AA, CA, CC, and BB types were 10% (5/50), 14% (7/50), 74% (37/50), and 2% (1/50), respectively. On postoperative day 2, 76% of cases were abnormal or unresolved (38/50), while 24% were normal or resolved (12/50). There were significant decreases in MEP both before and after adenotonsillectomy (p's<0.001). However, there were no significant differences in the MEPs measured on postoperative days 1 and 2. There were no significant differences between the right and left ears with regard to the MEPs on the preoperative day, or postoperative days 1 and 2.

CONCLUSIONS

Immediate E-tube dysfunction is a relatively common complication in children after adenotonsillectomy. Therefore, in the setting of immediate E-tube dysfunction, it is important to properly plan postoperative care and management.

Long-term Subjective and Objective Outcomes of Adenotonsillectomy in Korean Children With Obstructive Sleep Apnea Syndrome

OBJECTIVES

Adenotonsillar hypertrophy is the most common etiology in pediatric obstructive sleep apnea syndrome (OSAS), and adenotonsillectomy is the mainstay of treatment modalities. This study evaluates the long-term effectiveness of adenotonsillectomy in children with OSAS.

METHODS

Subjective symptoms evaluated with a 7-point Likert scale and objective respiratory disturbances evaluated by polysomnography were compared before and after adenotonsillectomy.

RESULTS

A total of 17 children with OSAS aged 4-15 years (mean age, 6.65±3.02 years; male:female, 13:4) completed the study. The mean follow-up period was 57 months (range, 30 to 98 months). Significant changes were found in apnea-hypopnea index (from 12.49±12.96 to 1.96±2.01, P<0.001), apnea index (from 5.64±7.57 to 0.53±0.78, P=0.006), minimum SaO2 (from 81.88±14.36 to 92.76±4.31, P=0.003), snoring (from 43.28±70.63 to 10.70±13.72, P=0.042), and arousal index (from 19.58±7.57 to 11.36±3.99, P=0.006) after adenotonsillectomy. Significant changes were also found after surgery in most of symptoms including snoring, witnessed apnea, morning headache, mouth breathing, gasping during sleep, restless sleep, nasal obstruction, and difficulty with morning arousal. Long-term surgical cure rate and response rate were 47.1% (8/17) and 70.6% (12/17), respectively.

CONCLUSION

Most of subjective OSAS symptoms and objective respiratory disturbances improved continuously about 5 years after adenotonsillectomy in children with OSAS. However, close follow-up and a sufficient observation period are necessary because of the risk for long-term incomplete resolution.

Blood Pressure after Surgery among Obese and Nonobese Children with Obstructive Sleep Apnea

Objectives

Treating obstructive sleep apnea in children is found to be associated with blood pressure decreases. However, exactly how adenotonsillectomy (T&A) affects blood pressure in obese and nonobese children remains unclear. This study assesses how obesity affects blood pressure in children with sleep apnea after T&A.

Study Design

Case series with chart review.

Setting

A tertiary referral center.

Subjects and Methods

From 2010 to 2012, a total of 78 children were included. Based on propensity score methods (age, sex, and preoperative apnea-hypopnea index matched), children were assigned to either the obese group (n = 39) or the nonobese group (n = 39). All children received adenotonsillectomy. We recorded clinical symptoms, preoperative overnight polysomnography (PSG), and subsequent PSG within 3 months after T&A. We measured blood pressure 3 times before PSG (nocturnal blood pressure) and after PSG (morning blood pressure) in a sleep laboratory.

Results

Following surgery, the nonobese group had a significantly decreased nocturnal diastolic blood pressure (DBP) index (–12.0 to −18.8, P = .018), morning systolic blood pressure (SBP; 111.1 to 105.8 mm Hg, P = .014), SBP index (–5.4 to −10.9, P = .008), and DBP (–12.0 to −18.7, P = .023). Nevertheless, all blood pressure parameters in the obese group were not significantly changed postoperatively. The nonobese group improved more than obese group in nocturnal and morning DBP and DBP index by 2-way analysis of variance.

Conclusion

Among the children receiving T&A as treatment for OSA, nonobese children improved more than obese children did in terms of blood pressure, allowing us to infer that obese children with OSA may benefit less from T&A in cardiovascular morbidities.

Influence of Tonsillar Size on OSA Improvement in Children Undergoing Adenotonsillectomy

Objective

To determine if pediatric obstructive sleep apnea (OSA) improves after adenotonsillectomy (AT) regardless of tonsil size.

Study Design

Case series with chart review.

Setting

Pediatric Otolaryngology Department, Johns Hopkins Hospital.

Subjects

Seventy children 1 to 18 years of age who underwent polysomnography (PSG) before and after AT.

Methods

Tonsil size was evaluated using the Brodsky grading scale.

Results

Children were stratified by tonsil size as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). There was a significant improvement in obstructive apnea-hypopnea index (oAHI), apnea index (AI), and saturation nadir across all 3 groups after AT. Preoperative oAHI, AI, and hypopnea index (HI) were similar regardless of tonsil size ( P > .05). Overall, oAHI improved from a median of 11.8 ± 21.7 to 2.0 ± 6.1 events/h, with 40% (28/70) of children having complete resolution. The oAHI ( P < .0001-0.02), AI ( P < .0001-0.017), HI ( P < .0001-0.058), and saturation nadir ( P < .0001-0.017) significantly improved for the 2+, 3+, and 4+ groups. Only the HI ( P = .058) in the 2+ group did not. The median oAHI improvement was 3.4 ± 26.4 events/h in the 2+ group, 8.3 ± 16.6 events/h in the 3+ group, and 12.3 ± 19.5 events/h in the 4+ group, with 25% (5/20), 50% (18/36), and 36% (5/14), respectively, having complete resolution. There was no correlation between OSA severity and tonsil or adenoid size ( P > .32).

Conclusion

Tonsil size did not correlate with OSA severity. While a larger proportion of patients classified as 3+ and 4+ had complete resolution after surgery, significant improvement was seen in AI and saturation nadir even in those classified as 2+.

Endothelial dysfunction and oxidative stress in children with sleep disordered breathing: role of NADPH oxidase

OBJECTIVE

Oxidative stress plays a crucial role in impairing endothelial function in sleep disordered breathing (SDB) but the underlying mechanism is still undefined. The objective of this study was to evaluate the interplay between oxidative stress, assessed by serum isoprostanes (8-iso-PGF2α) and soluble NOX2-dp (sNOX2-dp), and endothelial function, assessed by flow-mediated dilation (FMD), in children with SDB and healthy controls (HC).

METHODS

One-hundred forty-four children including 45 with primary snoring (PS), 22 with obstructive sleep apnea (OSA) and 67 HC were recruited in this study; in 15 out of 22 OSA children FMD, serum 8-iso-PGF2α and sNOX2-dp were assessed before and after one month post adeno-tonsillectomy (AT).

RESULTS

Compared with HC, OSA and PS children had significantly higher sNOX2-dp and serum 8-iso-PGF2α levels and lower FMD; compared with PS, FMD was significantly lower in OSA children. No significant difference for sNOX2-dp and serum 8-iso-PGF2α was observed between OSA and PS children. FMD was inversely correlated with sNOX2-dp levels (p<0.001) and with serum 8-iso-PGF2α (p<0.001). In multiple linear regression analysis, sNOX2-dp (p<0.001) and serum 8-iso-PGF2α (p<0.001) were the only independent predictive variables associated with FMD. AT significantly decreased sNOX2-dp and serum 8-iso-PGF2α levels (from 38.2±8.8 to 22.4±11.1 pg/ml, p<0.001, and from 281.4±69.7 to 226.0±66.4 pg/ml, p<0.001, respectively); conversely, FMD significantly increased after AT in OSA children (from 3.0±1.5 to 8.0±2.8%, p<0.001).

CONCLUSION

This study suggests that NOX2-derived oxidative stress is involved in artery dysfunction in SDB children. Such hypothesis is reinforced by FMD improvement after AT coincidentally with oxidative stress lowering.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02247167.

Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children

OBJECTIVE

The objective of this study was to evaluate the diagnostic reliability of home respiratory polygraphy (HRP) in children with a clinical suspicion of OSA-hypopnea syndrome (OSAS).

METHODS

A prospective blind evaluation was performed. Children between the ages of 2 to 14 years with clinical suspicion of OSAS who were referred to the Sleep Unit were included. An initial HRP followed by a later date, same night, in-laboratory overnight respiratory polygraphy and polysomnography (PSG) in the sleep laboratory were performed. The apnea-hypopnea index (AHI)-HRP was compared with AHI-PSG, and therapeutic decisions based on AHI-HRP and AHI-PSG were analyzed using intraclass correlation coefficients, Bland-Altman plots, and receiver operator curves (ROCs).

RESULTS

Twenty-seven boys and 23 girls, with a mean age of 5.3 ± 2.5 years, were studied, and 66% were diagnosed with OSAS based on a PSG-defined obstructive respiratory disturbance index ≥ 3/h total sleep time. Based on the availability of concurrent HRP-PSG recordings, the optimal AHI-HRP corresponding to the PSG-defined OSAS criterion was established as ≥ 5.6/h The latter exhibited a sensitivity of 90.9% (95% CI, 79.6%-100%) and a specificity of 94.1% (95% CI, 80%-100%).

CONCLUSIONS

HRP recordings emerge as a potentially useful and reliable approach for the diagnosis of OSAS in children. However, more research is required for the diagnosis of mild OSAS using HRP in children.

Detection of pediatric obstructive sleep apnea syndrome: history or anatomical findings?

OBJECTIVE

To assess how history and/or anatomical findings differ in diagnosing pediatric obstructive sleep apnea (OSA).

METHODS

Children aged 2-18 years were recruited and assessed for anatomical (ie, tonsil size, adenoid size, and obesity) and historical findings (ie, symptoms) using a standard sheet. History and anatomical findings, as well as those measures significantly correlated with OSA, were identified to establish the historical, anatomical, and the combined model. OSA was diagnosed by polysomnography. The effectiveness of those models in detecting OSA was analyzed by model fit, discrimination (C-index), calibration (Hosmer-Lemeshow test), and reclassification properties.

RESULTS

A total of 222 children were enrolled. The anatomical model included tonsil hypertrophy, adenoid hypertrophy, and obesity, whereas the historical model included snoring frequency, snoring duration, awakening, and breathing pause. The C-index was 0.84 for the combined model, which significantly differed from that in the anatomical (0.78, p = 0.003) and historical models (0.72, p < 0.001). The Hosmer-Lemeshow test revealed an adequate fit for all of the models. Additionally, the combined model more accurately reclassified 10.3% (p = 0.044) and 21.9% (p = 0.003) of all of the subjects than either the anatomical or historical model. Internal validation of the combined model by the bootstrapping method showed a fair model performance.

CONCLUSION

Overall performance of combined anatomical and historical findings offers incremental utility in detecting OSA. Results of this study suggest integrating both history and anatomical findings for a screening scheme of pediatric OSA.

Quality of life after adenotonsillectomy in children with obstructive sleep apnea: short-term and long-term results

OBJECTIVE

To assess short-term and long-term changes in quality of life after adenotonsillectomy (T&A) in children with obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Children aged 2-18 years old were enrolled. All subjects had clinical symptoms, overnight polysomnography diagnosis of OSA, and received T&A as treatment. Caregivers were asked to complete the OSA-18 survey before surgery, within 6 months after surgery (short-term), and more than 6 months after surgery (long-term).

RESULTS

A total of 114 children were included (mean age, 7.0±3.5 years; 75% boys). The mean OSA-18 total score was 71.5±16.0 before surgery. After surgery, the mean OSA-18 total score was significantly decreased in both the short-term (40.3±12.2, p<0.001) and the long-term (42.0±13.7, p<0.001). All five OSA-18 domains were also significantly decreased during short-term and long-term postoperative follow up (p<0.001). Short-term and long-term outcomes were compared. Mean OSA-18 total scores, sleep disturbance score, emotional distress score, daytime function score, and caregiver concerns score did not differ significantly between the short-term and long-term periods, while the physical symptom score was slightly higher in the long-term than the short-term period (9.7±3.3 vs. 8.7±3.0, p=0.02). Additionally, the physical symptoms score was higher in the long-term period in the female (p=0.01), older age (>6 years) (p=0.03), and non-obese (p=0.04) subgroups.

CONCLUSION

T&A improves short-term and long-term quality of life in children with OSA. Nevertheless, caregivers observed children with aggravation of physical symptoms of quality of life during long-term follow up, especially in the female, older, and non-obese subgroups.

An anatomically based analysis of objectively measured pediatric snoring: a pilot study

OBJECTIVE

To assess pediatric habitual snoring (PS) using home sleep test (HST) technology and attempt to correlate the objective components of PS to specific upper airway anatomy. In addition, the effects of adenotonsillectomy (±turbinoplasty) on objective measures of PS were evaluated.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Pediatric patients with a chief complaint of snoring and probable obstructive sleep apnea underwent an HST (SNAP Diagnostics, Wheeling, Illinois) with a detailed acoustical snoring analysis prior to adenotonsillectomy (±turbinoplasty). During surgery, detailed anatomical measurements were performed and correlated to snoring analysis results. After surgery, patients were offered another HST with snoring analysis. Data analysis was performed using descriptive statistics and statistical correlation with attention to the multiple-comparisons paradox.

RESULTS

Twenty-two patients (45% male; mean age, 5.4 years [range, 2.4-8.4 years]) completed the preoperative HST and operative measurements. Unlike typical adult snoring, only a minority of PS was from palatal flutter (mean palatal component, 24%; median, 10%). The resistance occurrence percentage (ROP, percentage of breathing events with snoring noise) was associated with body mass index (BMI; Spearman ρ=0.55; P=.017), subjective turbinate size (0.54; P=.032), palatal obstruction (0.63; P=.008), and mean oxygen saturation (-0.729; P=.0003) but not adenotonsillar hypertrophy. Twelve patients (54%) completed a postoperative HST. The ROP was significantly reduced (median, 20.5% vs 6.5%; P=.006, sign rank test) postoperatively. The magnitude of the ROP reduction was proportional to the volume of the removed tonsils (0.74; P=.022).

CONCLUSION

Pediatric snoring has different acoustical characteristics than adult snoring. Objective PS is associated with BMI, turbinate size, and palatal obstruction. Adenotonsillectomy (±turbinoplasty) may significantly reduce objective PS.

Psychological screening for the children with habitual snoring

OBJECTIVES

Adenotonsillar hypertrophy is the major determinants of habitual snoring in pediatric population. Behavioral hyperactivity and schooling problems have been repeatedly reported in these children, and it may underlie more extensive behavioral disturbances, particularly for the obese children. The aim of the present study is to evaluate the incidence and characteristics of emotional and behavioral problems using outpatient-based psychological screening tools in the children with habitual snoring.

METHODS

Total 235 patients and 170 controls, who aged 4-9 years were enrolled. Body mass index (BMI) z-score was obtained for age and gender and parental sleep-related breathing disorder (SRBD) questionnaire was used to assess severity of sleep-disordered breathing (SBD). Psychological assessment was performed using standardized questionnaires including Strength and Difficulties Questionnaire (SDQ), Children's Depression Inventory (CDI) and Screen for Child Anxiety Related Emotional Disorders (SCARED).

RESULTS

Children presenting habitual snoring had significantly higher mean scores on almost all scales of SDQ, and SCARED than community controls. Around 20% of the children with habitual snoring, compared with 10-11% of controls had significant levels of distress that could adversely impact treatment outcomes. There was no interaction between obstructive sleep apnea severity and behavioral ratings. The scores for emotional distress and hyperactivity were more prominent in the obese children. Significant psychological distress or impairment in social interactions was observed in children with higher SRBD scores.

CONCLUSIONS

Our findings suggest that the presence of habitual snoring in young children is associated wide spectrum of behavioral problems and the level of psychological distress might be evaluated at the time of the diagnosis.

DNA damage in children with obstructive adenotonsillar hypertrophy

The objective of this prospective, controlled study was to evaluate oxidative DNA damage in children with obstructive adenotonsillar hypertrophy. This study included 30 patients with obstructive adenotonsillar hypertrophy (male/female ratio, 3:2; age range, 3-9 y) scheduled to undergo tonsillectomy and adenoidectomy and 25 control subjects of similar age and sex with no adenotonsillar disease or airway obstruction. Urine and blood samples were obtained from each child for 8-hydroxy 2-deoxyguanosine (8-OhdG) and malondialdehyde (MDA) concentrations. There were significant differences in leukocyte (3.28 [0.69/10] vs 0.70 [0.15/10] dG) and urine 8-OhdG (8.22 [2.27/10] vs 5.26 [1.3/10] dG) levels in patients with obstructive adenotonsillar hypertrophy and healthy subjects (P < 0.001 for both). Plasma (2.98 [1.31] vs 1.14 [0.64] μM) and urine (1.77 [0.84] vs 0.56 [0.32] μM) MDA levels were also different (P < 0.001 for both). There were positive correlations between 8-OhdG in leukocyte DNA and plasma MDA (r = 0.648, P < 0.001) and between levels of urine 8-OhdG excretion and urine MDA (r = 0.588, P < 0.001). The DNA damage in children with adenotonsillar hypertrophy should be kept in mind, but further studies must be done with larger patient groups.

Cephalometric pattern and nasal patency in children with primary snoring: the evidence of a direct correlation

Introduction

Sleep disordered breathing (SDB) might affect craniofacial growth and children with obstructive sleep apnea syndrome present an increase in total and lower anterior heights of the face and a more anterior and inferior position of the hyoid bone when compared to nasal breathers.

Objective

To investigate the correlation between rhinomanometric and cephalometric parameters in children with primary snoring (PS), without apnea or gas exchange abnormalities.

Materials and Methods

Thirty children with habitual snoring (16 females and 14 males) aged 4–8 years (mean age 6.85±1.51 years) were selected by a SDB validate questionnaire. All subjects underwent lateral cephalometric, panoramic radiographies.

Results

In our sample 10 children (33%) had snoring 3 nights/week, 11 (37%) 4–6 nights/week and 9 (30%) every night/week. Overall 7 patients (23.3%) were affected by adenoid hypertrophy (AH), 4 (13.3%) by tonsillar hypertrophy (TH) and 13 (43.3%) by AH and TH. We found a more vertical position of the hyoid bone to the mandibular plane (H⊥VT) in patients with a higher frequency (7.3±2.7 vs 7.6±3.7 vs 10.9±2.5 in children snoring 3 nights/week, 4–6 nights/week and every night/week respectively; p = 0.032). Concerning nasal patency significant correlations were found with ANB (maxillary and jaw position with respect to the cranial base), NS∧Ar (growth predictor), sumangle, FMA (total divergence), SnaSnp∧GoMe (inferior divergence), BaN∧PtGn (facial growth pattern), Phw1_PsP (posterosuperior airway space), AHC3H (the horizontal distance between the most anterosuperior point of the hyoid bone and the third cervical vertebra).

Conclusion

The present study supports the relationship between nasal obstruction and specific craniofacial characteristics in children with primary snoring and lead us to hypothesize that nasal obstruction might explain the indirect link between snoring and cephalometric alterations.

Velopharyngeal dysfunction in children with Prader-Willi syndrome after adenotonsillectomy

INTRODUCTION

Prader-Willi syndrome (PWS) is a rare genetic disorder with an incidence rate of 1 in 10,000-30,000. Patients with PWS typically have symptoms related to hypotonia, obesity, and hypothalamic dysfunction. A high rate of obstructive sleep apnea (OSA) is found among this population of patients. Adenotonsillectomy has been advocated as a first line approach for treatment of OSA in patients with PWS. Velopharyngeal dysfunction (VPD) is a known complication of adenotonsillectomy. VPD can also be present in patients with global hypotonia, such as those with PWS. The objective of this study is to review the occurrence of VPD in patients with PWS after adenotonsillectomy for OSA.

METHODS

A retrospective review was performed of all patients with PWS and OSA from a tertiary pediatric hospital between the years of 2002 and 2012. Pre- and post-operative sleep studies and sleep disordered breathing symptoms, post-operative VPD assessment by the speech-language pathologist (SLP), and VPD treatments were evaluated.

RESULTS

Eleven patients (five males and six females), fitting the inclusion criteria, were identified. The age of the patient at the initial otolaryngologic evaluation ranged from 2 to 9 years. All patients underwent adenotonsillectomy for sleep disordered breathing. Four patients were diagnosed with post-operative hypernasality after assessment by a speech-language pathologist. The hypernasality ranged from mild to moderately severe. Of the four patients with hypernasality, two were found to have structural issues requiring surgery (pharyngeal flap). Both of the surgical patients experienced significant improvement in their VPD after surgery. The remaining two patients were found to have articulation error patterns that were considered more developmental in nature and both responded to speech therapy. All patients, except one, had improvement in their polysomnogram or sleep symptoms after adenotonsillectomy. However, three patients continue to require continuous positive airway pressure at night.

CONCLUSION

Velopharyngeal dysfunction may occur after adenotonsillectomy in patients with Prader-Willi Syndrome. Families should be counseled of this risk and the potential need for operative intervention to correct it.

Antiinflammatory therapy outcomes for mild OSA in children

BACKGROUND

OSA is highly prevalent in children and usually initially treated by adenotonsillectomy. Nonsurgical alternatives for mild OSA primarily consisting of antiinflammatory approaches have emerged, but their efficacy has not been extensively assessed.

METHODS

A retrospective review of clinically and polysomnographically diagnosed patients with OSA treated between 2007 and 2012 was performed to identify otherwise healthy children ages 2 to 14 years who fulfilled the criteria for mild OSA and who were treated with a combination of intranasal corticosteroid and oral montelukast (OM) for 12 weeks (ICS + OM). A subset of children continued OM treatment for 6 to 12 months.

RESULTS

A total of 3,071 children were diagnosed with OSA, of whom 836 fulfilled mild OSA criteria and 752 received ICS + OM. Overall, beneficial effects occurred in > 80% of the children, with nonadherence being documented in 61 children and adenotonsillectomy being ultimately performed in 12.3%. Follow-up polysomnography in a subset of 445 patients showed normalization of sleep findings in 62%, while 17.1% showed either no improvement or worsening of their OSA. Among the latter, older children (aged > 7 years; OR, 2.3; 95% CI, 1.43-4.13; P < .001) and obese children (BMI z-score > 1.65; OR: 6.3; 95% CI, 4.23-11.18; P < .000001) were significantly more likely to be nonresponders.

CONCLUSIONS

A combination of ICS + OM as initial treatment of mild OSA appears to provide an effective alternative to adenotonsillectomy, particularly in younger and nonobese children. These results support implementation of multicenter randomized trials to more definitively establish the role of ICS + OM treatment in pediatric OSA.

Inferior turbinate classification system, grades 1 to 4: development and validation study

OBJECTIVES/HYPOTHESIS

To develop a validated inferior turbinate grading scale.

STUDY DESIGN

Development and validation study.

METHODS

Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales (>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive clinic patients (n = 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two independent raters, and grading was repeated by each of the same two raters, two separate times for each patient.

RESULTS

In the development phase, 25% (grades 1-4) and 33% (grades 1-4) were the most useful systems. In the validation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to grade; the photo grading demonstrated a Cohen's kappa (κ) = 0.4671 ± 0.0082 (moderate inter-rater agreement). Live-patient grading with the 25% classification system demonstrated an overall inter-rater reliability of 71.5% (95% confidence interval [CI]: 64.8-77.3), with overall substantial agreement (κ = 0.704 ± 0.028). Intrarater reliability was 91.5% (95% CI: 88.7-94.3). Distribution for the 200 inferior turbinates was as follows: 25% quartile = grade 1, 50% quartile (median) = grade 2, 75% quartile = grade 3, and 90% quartile = grade 4. Mean turbinate size was 2.22 (95% CI: 2.07-2.34; standard deviation 1.02). Categorical κ was as follows: grade 1, 0.8541 ± 0.0289; grade 2, 0.7310 ± 0.0289; grade 3, 0.6997 ± 0.0289, and grade 4, 0.7760 ± 0.0289.

CONCLUSIONS

The 25% (grades 1-4) inferior turbinate classification system is a validated grading scale with high intrarater and inter-rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior turbinates.

LEVEL OF EVIDENCE

2c.

Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy

OBJECTIVE

The aim of our study was to investigate subclinical cardiac disturbances in patients with symptoms due to adenotonsillar hypertrophy (ATH) and the impact of adenotonsillectomy (AT) using conventional and novel echocardiographic measures.

MATERIAL AND METHODS

Thirty patients with grade 3 or 4 ATH (mean age: 7.86 ± 3.83 years; 10 females) and 30 healthy, age- and sex-matched volunteers (mean age, 8 ± 2.77; 14 females) were enrolled in the study. In addition to conventional two-dimensional and Doppler echocardiographic parameters, tissue Doppler parameters, including myocardial performance indices (MPIs) of both the right (RV) and left ventricle (LV), were studied. The severity of obstructive sleep apnea (OSA) was determined using the OSA-18 health quality questionnaire. The OSA-18 questionnaire and echocardiographic examination were repeated after AT in patients with ATH.

RESULTS

The total OSA-18 scores for the control, preoperative, and postoperative groups were 39.56 ± 19.98, 80.63 ± 22.32, and 44.10 ± 20.31, respectively. Conventional parameters were not different among the groups. The mean pulmonary artery pressure estimated using the Mahan formula was increased in the ATH group compared with that in the control group (21.72 ± 4.25 vs. 12.43 ± 3.83, respectively; p<0.001) and significantly improved after AT (21.72 ± 4.25 vs. 16.09 ± 4.53; p<0.001). The RV MPI was significantly different between the control and ATH groups (0.322 ± 0.052 vs. 0.383 ± 0.079, respectively; p=0.001). Both the LV and RV MPI significantly improved (0.515 ± 0.066 vs. 0.434 ± 0.052, p<0.001; and 0.383 ± 0.079 vs. 0.316 ± 0.058, p=0.018, respectively) after surgery for ATH.

CONCLUSIONS

Our study revealed that the patients with OSA-specific symptoms due to ATH had higher pulmonary artery pressure and impaired RV function according to novel echocardiographic parameters. Surgery for ATH seems to have an important effect on both LV and RV function.

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy

OBJECTIVES

Adenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya.

METHODS

This was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥ 25 mm Hg using the Chemla equation. Children with mPAP of ≥ 25 mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis.

RESULTS

Of the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%-29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR=3.0 [95% CI 1.08-8.44] p=0.035) and hyperactivity on history (OR=0.2 [95% CI 0.07-0.59] p=0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR=5.0 [95% CI 1.01-24.37] p=0.048).

CONCLUSION

One in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.

Quality of life after adenotonsillectomy for children with sleep-disordered breathing: a linear mixed model analysis

OBJECTIVE

To study changes in quality of life (QoL) after adenotonsillectomy (T&A) in children with sleep-disordered breathing (SDB), and to elucidate discrepancies in QoL improvements after T&A in children of different gender, age, adiposity status, and disease severity.

MATERIALS AND METHODS

Children aged 2-18 years were recruited. All children had SDB-related symptoms and underwent preoperative full-night polysomnography (PSG). Caregivers completed the first obstructive sleep apnea 18-items questionnaire (OSA-18) prior to T&A and the second OSA-18 survey within 3 months after surgery. Disease severity was defined as primary snoring (apnea/hypopnea index, AHI < 1), mild obstructive sleep apnea (OSA) (5 > AHI ≥ 1), and moderate-to-severe OSA (AHI ≥ 5). Discrepancies in OSA-18 score changes after T&A for different groups were assessed using the linear mixed model.

RESULTS

In total, 144 children were enrolled (mean age, 7.0 ± 3.6 years; 76% boy). The OSA-18 total score changes after surgery were not significantly different by gender (boys vs. girls), age group (≥ 6 years vs. < 6 years), or adiposity (obese vs. non-obese). The OSA-18 total score changes after surgery differed by disease severity (primary snoring vs. moderate-to-severe OSA, P = 0.004; mild OSA vs. moderate-to-severe OSA, P = 0.003). Children with moderate-to-severe OSA had greater improvement in OSA-18 total score after surgery than those with mild OSA or primary snoring.

CONCLUSIONS

Children with SDB had QoL improvement after T&A, as documented by OSA-18 score changes. The QoL improvement after T&A for SDB children increased as disease severity increased, and the improvement was not affected by gender, age, or adiposity.

Obstructive sleep apnea in obese community-dwelling children: the NANOS study

INTRODUCTION

Obesity in children is assumed to serve as a major risk factor in pediatric obstructive sleep apnea syndrome (OSAS). However, the prevalence of OSAS in otherwise healthy obese children from the community is unknown.

AIM

To determine the prevalence of OSAS in obese children identified and recruited from primary care centers.

METHODS

A cross-sectional, prospective, multicenter study. Spanish children ages 3-14 y with a body mass index (BMI) greater than or equal to the 95th percentile for age and sex were randomly selected, and underwent medical history, snoring, and Pediatric Sleep Questionnaire (PSQ) assessments, as well as physical examination, nasopharyngoscopy, and nocturnal polysomnography (NPSG) recordings.

RESULTS

Two hundred forty-eight children (54.4% males) with mean age of 10.8 ± 2.6 y were studied with a BMI of 28.0 ± 4.7 kg/m(2) corresponding to 96.8 ± 0.6 percentile when adjusted for age and sex. The mean respiratory disturbance index (RDI), obstructive RDI (ORDI), and obstructive apnea-hypopnea index (OAHI) were 5.58 ± 9.90, 5.06 ± 9.57, and 3.39 ± 8.78/h total sleep time (TST), respectively. Using ≥ 3/h TST as the cutoff for the presence of OSAS, the prevalence of OSAS ranged from 21.5% to 39.5% depending on whether OAHI, ORDI, or RDI were used.

CONCLUSIONS

The prevalence of obstructive sleep apnea syndrome (OSAS) in obese children from the general population is high. Obese children should be screened for the presence of OSAS. ClinicalTrials.gov identifier: NCT01322763.

Discrepancy between Objective and Subjective Outcomes after Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome

Objective

Adenotonsillectomy (T&A) is the first line therapy for pediatric obstructive sleep apnea (OSA); however, inconsistency between objective and subjective outcomes perplexes physicians. This study investigates changes of objective and subjective outcomes in children with OSA after T&A, in particular, to elucidate correlations and discrepancies between these 2 measures.

Study Design

Case series with record review.

Setting

Tertiary referral medical center.

Subjects and Methods

Symptomatic children with polysomnographic diagnosis of OSA (apnea-hypopnea index [AHI] > 1) were included. All children underwent T&A to treat OSA, along with completely objective (polysomnography) and subjective (Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire [OSA-18]) measures before and 3 months after surgery.

Results

One hundred nineteen children were included (mean age, 6.9 ± 3.3 years; 76% boys). Adenotonsillectomy significantly reduced AHI from 15.4 ± 21.2 per hour to 1.6 ± 2.5 per hour ( P < .001). The OSA-18 scores were significantly improved after surgery ( P < .001). A weak but statistically significant positive correlation was found between AHI and OSA-18 scores preoperatively (ρ = 0.22, P = .016) but not postoperatively (ρ = 0.04, P = .677). Among those cases with residual OSA after surgery, only 6% (3/54) had a residual effect on quality of life (OSA-18 score > 60).

Conclusion

Adenotonsillectomy improves both objective and subjective outcomes. After surgery, quality of life significantly improved subjectively, despite an incomplete resolution of OSA objectively, leading to a better correlation between objective and subjective measures before as opposed to after surgery. Discrepancy between the 2 measures warrants an evaluation of a child both objectively and subjectively when treating OSA.

Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study

OBJECTIVE

To evaluate the efficacy of adenotonsillectomy (AT) in the treatment of children with obstructive sleep apnea (OSA) in a 3-y prospective, longitudinal study with analysis of risk factors of recurrence of OSA.

STUDY DESIGN

An investigation of children (6 to 12 y old) with OSA documented at entry and followed posttreatment at 6, 12, 24, and 36 mo with examination, questionnaires, and polysomnography. Multivariate generalized linear modeling and hierarchical linear models analysis were used to determine contributors to suboptimal long-term resolution of OSA, and Generalized Linear Models were used for analysis of risk factors of recurrence.

RESULTS

Of the 135 children, 88 terminated the study at 36 months post-AT. These 88 children (boys = 72, mean age = 8.9 ± 2.7 yersus boys 8.9 ± 2.04 y, girls: 8.8 ± 2.07 y; body mass index [BMI] = 19.5 ± 4.6 kg/m(2)) had a preoperative mean apnea-hypopnea index (AHI0) of 13.54 ± 7.23 and a mean postoperative AHI at 6 mo (AHI6) of 3.47 ± 8.41 events/h (with AHI6 > 1 = 53.4% of 88 children). A progressive increase in AHI was noted with a mean AHI36 = 6.48 ± 5.57 events/h and AHI36 > 1 = 68% of the studied group. Change in AHI was associated with changes in the OSA-18 questionnaire. The residual pediatric OSA after AT was significantly associated with BMI, AHI, enuresis, and allergic rhinitis before surgery. From 6 to 36 mo after AT, recurrence of pediatric OSA was significantly associated with enuresis, age (for the 24- to 36-mo period), postsurgery AHI6 (severity), and the rate of change in BMI and body weight.

CONCLUSIONS

Adenotonsillectomy leads to significant improvement in apnea-hypopnea index, though generally with incomplete resolution, but a worsening over time was observed in 68% of our cases.

Associations between adenotonsillar hypertrophy, age, and obesity in children with obstructive sleep apnea

OBJECTIVE

To investigate the contributions of adenoid and tonsil size to childhood obstructive sleep apnea (OSA) and the interactions between adenotonsillar hypertrophy, age, and obesity in children with OSA.

METHODS

In total, 495 symptomatic patients were recruited. The patients were assigned to four groups according to age: toddler (age 1-3, n=42), preschool (age 3-6, n=164), school (age 6-12, n=200), and adolescence (age 12-18, n=89). All subjects had tonsil size graded by otolaryngologists, adenoid size determined on lateral radiographs (Fujioka method), and a full-night polysomnography. The apnea-hypopnea index (AHI), adenoid size, and tonsil size were compared in obese and non-obese children in the four age groups. Adjusted odds ratios (ORs) and 95% confidence interval (CI) of adenotonsillar hypertrophy and OSA risk were estimated by multi-logistic regression.

RESULTS

The AHI was positively related to tonsil grade (r=0.33, p <0.001) and adenoid size (r=0.24, p <0.01) in all patients. Tonsil grade was positively related to AHI in all four age groups. Adenoid size was positively related to AHI in the toddler, preschool, school groups, but not in the adolescent group (r=0.11, p=0.37). Tonsil grade and adenoid size were both positively related to AHI in obese and non-obese children. In the regression model, obesity (OR=2.89; 95% CI 1.47-5.68), tonsillar hypertrophy (OR=3.15; 95% CI 2.04-4.88), and adenoidal hypertrophy (OR=1.89; 95% CI 1.19-3.00) significantly increased OSA risk.

CONCLUSIONS

Adenotonsillar hypertrophy and obesity are the major determinants of OSA in children. However, the influence of adenoid size decreases in adolescence.

Otolaryngologic findings in prepubertal obese children with sleep-disordered breathing

OBJECTIVE

To evaluate otolaryngologic findings in obese prepubertal children with sleep-disordered breathing.

METHODS

We prospectively evaluated 29 obese children referred by pediatric endocrinologist, complaining of snoring and without a history of nasal surgery or removal of the palatine tonsils and/or adenoids. Patients underwent ear, nose and throat (ENT) examination, endoscopy, measurements of weight, height, calculation of body mass index (BMI), assessment of BMI z-score and polysomnography, from which were divided into two groups: those with obstructive sleep apnea syndrome (nine children) and those with primary snoring (20 children). Then we proceeded to the statistical analysis of the data collected.

RESULTS

The groups did not differ in age, gender, weight, height, BMI and BMI z-score. Among the findings of the ENT examination, the adenoid size was the only one that differed between the groups (p = 0.01).

CONCLUSION

The evaluation of the adenoid size is an important in obese children with symptoms of sleep-disordered breathing and is related to the presence of obstructive sleep apnea syndrome.

Central sleep apnea in obese children with sleep-disordered breathing

OBJECTIVES

In contrast to obstructive sleep apnea (OSA), central sleep apnea (CSA) in obese children has received lesser attention. As pediatric CSA is more prevalent than expected and adversely impacts health, this study aims to elucidate the major factors associated with central apnea index (CAI) and compare CSA between obese and non-obese children.

METHODS

Retrospective analysis was performed in a tertiary referral medical center. Children with sleep-disordered breathing (SDB) ranging from 2-18 years old were enrolled. All participants completed history taking, otolaryngological examination and overnight polysomnography. CSA was defined as having CAI exceeding 1 h(-1). CAI and the prevalence of CSA were analyzed in children of different age groups, weight statuses and adenotonsillar sizes.

RESULTS

A total of 487 cases were included. The prevalence of CSA was 13.3% (65/487). CAI was negatively correlated with age (r=-0.32, P<0.001). Obese children had a significantly lower CAI than that of non-obese ones (0.20 ± 0.36 vs 0.48 ± 0.82 h(-1), P<0.001). Multiple linear regression analysis demonstrated a relationship between CAI, age and obesity as 'CAI=0.883-0.055 × Age -0.22 × (Obesity)'.

CONCLUSIONS

In children with SDB, younger ones have a significantly higher CAI than older ones. Additionally, obese children had a lower CAI than non-obese ones.

Three-dimensional evaluation of the relationship between nasopharyngeal airway shape and adenoid size in children

Objective

To evaluate the shapes and sizes of nasopharyngeal airways by using cone-beam computed tomography and to assess the relationship between nasopharyngeal airway shape and adenoid hypertrophy in children.

Methods

Linear and cross-sectional measurements on frontal and sagittal cross-sections containing the most enlarged adenoids and nasopharyngeal airway volumes were obtained from cone-beam computed tomography scans of 64 healthy children (11.0 ± 1.8 years), and the interrelationships of these measurements were evaluated.

Results

On the basis of frontal section images, the subjects' nasopharyngeal airways were divided into the following 2 types: the broad and long type and the narrow and flat type. The nasopharyngeal airway sizes and volumes were smaller in subjects with narrow and flat airways than in those with broad and long airways (p < 0.01). Children who showed high adenoid-nasopharyngeal ratios on sagittal imaging, indicating moderate to severe adenoid hypertrophy, had the narrow and flat type nasopharyngeal airway (p < 0.01).

Conclusions

Cone-beam computed tomography is a clinically simple, reliable, and noninvasive tool that can simultaneously visualize the entire structure and a cross section of the nasopharyngeal airway and help in measurement of adenoid size as well as airway volume in children with adenoid hypertrophy.

Comparing the clinical profile of non obese children with sleep apnea and snoring

Few studies in the literature have looked into the cardiovascular and metabolic effects of Obstructive Sleep Apnea Syndrome (OSAS) in children.

Objective

This study aims to evaluate the metabolic profile of non-obese children with OSAS.

Methods

Fifty-two children were enrolled in this study, 21 girls and 31 boys. Patients were divided into two groups: OSAS (28 children) and Snore (22 children) according to polysomnographic evaluation. All children were submitted to ENT examination, measurements of weight, height and blood pressure. Blood samples were tested for hemoglobin, hematocrit, fasting glucose, fasting insulin, triglycerides, total cholesterol, HDL, LDL, VLDL, TSH and T4. The gathered data sets were compared between groups and also within the OSAS group according to the severity of the syndrome.

Results

The children from both groups had no alterations in blood pressure levels. The results of the blood tests were normal for both groups. Results of hemoglobin, hematocrit, and HDL were all significantly higher in the Snore group when compared to the OSAS group; by their turn, VLDL levels were higher in the OSAS group. There was no statistical difference between the groups based on OSAS severity.

Conclusion

Non-obese children with OSAS present no significant alterations in metabolic tests or blood pressure levels.

Serum lipids alterations in adenoid hypertrophy or adenotonsillar hypertrophy children with sleep disordered breathing

OBJECTIVES

We aimed to investigate metabolic parameters in children with adenoid hypertrophy (AH) only or adenotonsillar hypertrophy (ATH) and compare them with healthy controls.

METHODS

Forty-four prepubertal children aged 6-12 years who were obstructive symptoms and 16 healthy children were recruited in this study. All children underwent a complete otolaryngologic examination and sleep screening. The patients were divided into three groups according to obstruction type: normal, AH (adenoid grade III or IV, tonsil grade 1 or 2), and ATH (adenoid grade III or IV, tonsil grade 3 or 4). All participants underwent hematologic and biochemical tests including fasting blood glucose, insulin, and plasma lipids.

RESULTS

(1) The children with AH and ATH had lower high-density lipoprotein cholesterol (HDL-C), when compared to normal children. (2) The level of HDL-C was negatively correlated with the sum of adenoid and tonsillar size scores and the apnea-hypopnea index (AHI) (r=-0.477, p<0.001 vs. r=-0.548, p<0.001, respectively). There was a modest association between HDL-C and minimal SpO₂ (r=0.332, p=0.009). (3) Stepwise multiple regression analysis identified the AHI, triglycerides, and fasting insulin as independent predictors for HDL-C.

CONCLUSIONS

Patients with adenoid and tonsil hypertrophy had low HDL-C. HDL-C levels are inversely related to the sum of adenoid and tonsillar size scores and AHI in SDB children. HDL-C may be a sensitive indicator of serum lipids changes in SDB children.