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Wang ST, Kang KT, Chang CF, Lin MT, Hsu WC. Voice Change After Adenotonsillectomy in Children: A Systematic Review and Meta-Analysis. Laryngoscope 2024; 134:2538-2550. [PMID: 37909678 DOI: 10.1002/lary.31140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/18/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Adenotonsillectomy is one of the most common surgical procedures performed on children. Caregivers are often concerned about voice change after the procedure, and such concerns remain unsettled. This meta-analysis analyzed voice change in children after adenotonsillectomy. DATA SOURCES The PubMed, Medline, EMBASE, and Cochrane databases. REVIEW METHODS The study protocol was registered on PROSPERO. Two authors independently searched for articles using keywords "adenoidectomy," "tonsillectomy, "voice," "nasalance,"and "speech." English articles specifying voice changes after adenotonsillectomy were pooled with standardized mean difference (SMD) using random-effects model. Evaluation methods were computerized acoustic voice analysis, aerodynamic analysis, nasometer, rhinomanometry, evaluations from a speech-language pathologist or otolaryngologist, and a caregiver assessment questionnaire. RESULTS Twenty-three studies with 2154 children were analyzed (mean age: 8.0 y; 58% boys; mean sample size: 94 children). Due to insufficient data for other outcome variables, this meta-analysis only summarized changes in the computerized acoustic voice analysis 1 month and 3 months after surgery. The computerized acoustic analysis revealed significant changes in jitter (SMD = -0.36; 95% confidence interval [CI]: -0.60 to -0.11), shimmer (SMD = -0.34; 95% CI: -0.57 to -0.11), and soft phonation index (SMD = -0.36; 95% CI: -0.57 to -0.15) at 1 month after surgery. Parameters including fundamental frequency, jitter, noise-to-harmonics ratio, and shimmer were not significantly changed at 3 months after surgery. CONCLUSIONS This meta-analysis observed small improvements in jitter, shimmer, and soft phonation index 1 month after surgery. No significant effects were observed in voice outcomes 3 months after surgery. Laryngoscope, 134:2538-2550, 2024.
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Affiliation(s)
- Sz-Ting Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Chi-Fen Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tzer Lin
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, Hsiao Chung-Cheng Hospital, New Taipei City, Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Otolaryngology, College of Medicine, National Taiwan University, Taipei, Taiwan
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Martin E, Frank M, Nguyen C, Bhatt J, Huoh K, Ahuja G, Pham N. Supplemental oxygen requirement after tonsillectomy in children >3 years of age. Int J Pediatr Otorhinolaryngol 2024; 178:111893. [PMID: 38382259 DOI: 10.1016/j.ijporl.2024.111893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION The indications for postoperative admission after tonsillectomy in children >3 years of age are less well defined than for children <3 years old, and typically include severe obstructive sleep apnea (OSA), obesity, comorbidities, or behavioral factors. Inpatient care after tonsillectomy typically consists of respiratory monitoring and support, as respiratory compromise is the most common complication after pediatric tonsillectomy. We aim to evaluate risk factors associated with postoperative oxygen supplementation and to identify high risk populations within the admitted population who use additional resources or require additional interventions. METHODS Retrospective chart review of patients between the ages of 3 and 18 years old who underwent tonsillectomy by four surgeons at a tertiary care children's hospital was performed. Data including demographics, comorbidities, surgical intervention, pre- and postoperative AHI, admission, postoperative oxygen requirement, and postoperative complications was collected and analyzed. RESULTS There were 401 patients included in the analysis. Of the patients in this study, 65.59% were male, 43.39% were Latino, and 53.87% were ages 3 to 7. Of the 397 patients with a record for supplemental oxygen, 36 (9.07%) received supplemental oxygen. The LASSO regression odds ratios (OR) found to be important for modeling supplemental oxygen use (in decreasing order of magnitude) are BMI ≥35 (OR = 2.30), pre-op AHI >30 (OR = 2.28), gastrointestinal comorbidities (OR = 2.20), musculoskeletal comorbidities (OR = 1.91), cardiac comorbidities (OR = 1.20), pulmonary comorbidities (OR = 1.14), and BMI 30 to <35 (OR = 1.07). Female gender was found to be negatively associated with risk of supplemental oxygen use (OR = 0.84). Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement. CONCLUSION BMI ≥30, pre-op AHI >30, male gender, and gastrointestinal, musculoskeletal, cardiac, and pulmonary comorbidities are all associated with postoperative supplemental oxygen use. Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.
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Affiliation(s)
- Elaine Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
| | - Madelyn Frank
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Cecilia Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jay Bhatt
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Kevin Huoh
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Gurpreet Ahuja
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Nguyen Pham
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
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Springford LR, Griffiths M, Bajaj Y. Management of paediatric sleep-disordered breathing. Br J Hosp Med (Lond) 2024; 85:1-6. [PMID: 38416524 DOI: 10.12968/hmed.2023.0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Paediatric sleep-disordered breathing is a common condition which varies in severity from snoring to obstructive sleep apnoea. Paediatric sleep-disordered breathing is usually diagnosed clinically, with investigations such as polysomnography reserved for more complex cases. Management can involve watching and waiting, medical or adjunct treatments and adenotonsillectomy. National working groups have sought to standardise the pathway for surgery and improve the management of surgical and anaesthetic complications. Current guidelines use age, weight and comorbidities to stratify risk for these surgical cases. This article summarises these recommendations and outlines the important factors that indicate cases that may be more suitable for management in secondary and tertiary units. Appropriate case selection will reduce pressure on tertiary units while maintaining training opportunities in district general hospitals.
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Affiliation(s)
- Laurie R Springford
- Department of Ear, Nose, Throat and Head and Neck Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | - Yogesh Bajaj
- Department of Ear, Nose, Throat and Head and Neck Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Hazkani I, Serino MA, Thompson DM, Lavin J. Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy. Laryngoscope 2023; 133:3582-3587. [PMID: 36960875 DOI: 10.1002/lary.30673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2-4 h of PACU admission. OBJECTIVE To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation. METHODS A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery. RESULTS 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit. CONCLUSIONS The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended. LEVEL OF EVIDENCE 4 Laryngoscope, 133:3582-3587, 2023.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Maeve A Serino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Liu K, Liu C. In Response to Is Polysomnography Both Reliable and Accessible to Predict Respiratory Events. Laryngoscope 2023. [PMID: 36815618 DOI: 10.1002/lary.30603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Katie Liu
- Department of Anesthesiology, Pediatric Anesthesiology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, USA
| | - Christopher Liu
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, USA
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Predictors of overnight postoperative respiratory complications in obese children undergoing adenotonsillectomy for obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2022; 162:111334. [PMID: 36209625 DOI: 10.1016/j.ijporl.2022.111334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/24/2022] [Accepted: 10/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A. METHODS A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O2 desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications. RESULTS Lower O2 saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR = 0.953, 95% CI = 0.91-0.99, P = 0.021), as was sleep time with O2 saturation less than 90% (OR = 1.04, 95% CI = 1.00-1.07, P = 0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O2 saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O2 < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event. CONCLUSIONS O2 saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O2 saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O2 sat <90% during PSG due to increased risk of overnight postoperative respiratory complications.
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Tsampalieros A, Murto K, Barrowman N, Vaillancourt R, Bromwich M, Monsour A, Chan T, Katz SL. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med 2022; 18:2405-2413. [PMID: 35801349 PMCID: PMC9516588 DOI: 10.5664/jcsm.10120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep-disordered breathing is commonly treated with adenotonsillectomy. Our study objective was to describe perioperative opioid dosing in children with a range of medical complexity evaluated for obstructive sleep-disordered breathing undergoing adenotonsillectomy and to investigate its association with postoperative respiratory adverse events (PRAEs). METHODS A retrospective chart review of children who underwent adenotonsillectomy and had preoperative polysomnography performed was conducted. PRAEs included requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Multivariable logistic regression was performed to examine for associations between covariates and PRAEs. RESULTS The cohort included 374 children with obstructive sleep-disordered breathing, median (interquartile range) age 6.1 (3.9, 9.3) years; 344 (92%) had obstructive sleep apnea (apnea-hypopnea index > 1 events/h) while 30 (8%) had a normal polysomnogram (apnea-hypopnea index < 1 events/h). The median (interquartile range) postoperative morphine-equivalent dose administered was 0.17 (0.09, 0.25) mg/kg. Sixty-six (17.6%) experienced at least 1 PRAE. Multivariable modeling identified the following predictors of PRAE: younger age at surgery (odds ratio 0.90, 95% confidence interval 0.83, 0.98), presence of cardiac comorbidity (odds ratio 2.07, 95% confidence interval 1.09, 3.89), and presence of airway anomaly (odds ratio 3.48, 95% confidence interval 1.30, 8.94). Higher total apnea-hypopnea index and morphine-equivalent dose were associated with PRAE risk, and an interaction between these variables was detected (P = .01). CONCLUSIONS This study identified opioid dose in morphine equivalents to be a strong predictor of PRAE. Additionally, severity of obstructive sleep apnea and postoperative morphine-equivalent dose contributed together and independently to the occurrence of PRAEs. Attention to opioid dosing, particularly among medically complex children with obstructive sleep-disordered breathing, is required to mitigate risk of PRAEs. CITATION Tsampalieros A, Murto K, Barrowman N, et al. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med. 2022;18(10):2405-2413.
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Affiliation(s)
- Anne Tsampalieros
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Kimmo Murto
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Anesthesiology and Pain Medicine, Ottawa, Canada
| | - Nicholas Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Canada
| | - Regis Vaillancourt
- Children’s Hospital of Eastern Ontario, Department of Pharmacy, Ottawa, Canada
| | - Matthew Bromwich
- Children’s Hospital of Eastern Ontario, Department of Surgery, Ottawa, Canada
| | - Andrea Monsour
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Theadora Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sherri L. Katz
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Canada
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Hazkani I, Stein E, Ching Siong T, Hill R, Dautel J, Patel MD, Vaughn W, Cordray H, Patel E, Clark A, Raol N, Evans S. Incidence and Risk Factors Associated with Respiratory Compromise in Planned PICU Admissions Following Tonsillectomy. Ann Otol Rhinol Laryngol 2022:34894221115754. [PMID: 35983621 DOI: 10.1177/00034894221115754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Review the incidence and factors associated with respiratory compromise requiring intensive care unit level interventions in children with planned admission to the pediatric intensive care unit (PICU) following tonsillectomy or adenotonsillectomy (T/AT). STUDY DESIGN Retrospective cohort study. METHODS Review of all patients with PICU admissions following T/AT from 2015 to 2020 at a tertiary care pediatric hospital. Patient demographics, underlying comorbidities, operative data, and respiratory complications during PICU admission were extracted. RESULTS Seven hundred and seventy-two patients were admitted to the PICU following T/AT, age 6.1 ± 4.6 years. All children were diagnosed with obstructive sleep apnea or sleep-disordered breathing (mean pre-operative apnea-hypopnea index 29 ± 26.5 and O2 nadir 77.1% ± 11.1). Neuromuscular disease, enteral feed dependence, and obesity were common findings (N = 240 (31%), N = 106 (14%), and N = 209 (27%) respectively). Overall, 29 patients (3.7%) developed respiratory compromise requiring PICU-level support, defined as new-onset continuous or bilevel positive airway pressure support (n = 25) or reintubation (n = 9). Three patients were diagnosed with pulmonary edema. Multivariable regression analysis demonstrated pre-operative oxygen nadir and enteral feed dependence were associated with respiratory compromise (OR = 0.97, 95% CI 0.94-0.99, P = .04; OR = 6.3, 95% CI 2.36-52.6, P = .001 respectively). CONCLUSIONS Our study found respiratory compromise in 3.7% of patients with planned PICU admissions following T/AT. Oxygen nadir and enteral feeds were associated with higher respiratory compromise rates. Attention should be given to these factors in planning for post-operative disposition.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eli Stein
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Tey Ching Siong
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Robert Hill
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Jacob Dautel
- School of Medicine, Mercer University, Macon, GA, USA
| | - Mital D Patel
- School of Medicine, Mercer University, Macon, GA, USA
| | | | - Holly Cordray
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA, USA.,Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Eshan Patel
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA, USA.,College of Arts and Sciences, Emory University, Atlanta, GA, USA
| | - Addison Clark
- Department of Biological and Environmental Sciences, Georgia College and State University, Milledgeville, GA, USA
| | - Nikhila Raol
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA, USA.,Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sean Evans
- School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA, USA.,Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Lim J, Garigipati P, Liu K, Johnson RF, Liu C. Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea. Laryngoscope 2022; 133:1251-1256. [PMID: 35932233 DOI: 10.1002/lary.30317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/26/2022] [Accepted: 07/01/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). METHODS Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. RESULTS There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2 < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. CONCLUSIONS Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
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Affiliation(s)
- Jorena Lim
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Priyanka Garigipati
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Katie Liu
- Department of Anesthesiology, Pediatric Anesthesiology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
| | - Christopher Liu
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, U.S.A
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Benedek P, Keserü F, Kiss G, Bella Z, Rovó L, Katona G, Bikov A, Csoma B, Lázár Z. Postoperative respiratory complications in children with obstructive sleep apnoea syndrome. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:162-168. [PMID: 35612508 PMCID: PMC9132002 DOI: 10.14639/0392-100x-n1803] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/29/2021] [Indexed: 02/07/2023]
Abstract
Objective We aimed to prospectively assess the effect of comorbidities on the occurrence of postoperative respiratory complications (PoRCs) after adenotonsillectomy in children with obstructive sleep apnoea syndrome (OSA) and whether otherwise healthy children need a higher level of postoperative monitoring. Methods 577 children who had OSA and underwent adenotonsillectomy were enrolled. The effects of demographics, comorbidities and OSA on PoRCs were investigated with logistic regression analysis. Results The PoRC rate was 4.3%. Postoperative oxygen desaturations were more marked in patients with comorbidities (p = 0.005). The presence of comorbidity increased the risk of PoRCs (odds ratio 4.234/3.226-5.241, 95% confidence intervals, p < 0.001). There was no difference in apnoea-hypopnoea index (AHI) values between comorbid patients with and without PoRCs [8.2 (3.8-50.2) vs 14.3 (11.7-23.3)]. (p = 0.37). In the group of patients without comorbidities, PoRCs were associated with a higher AHI [14.7 (3.4-51.3) vs 3.9 (2.0-8.0), p < 0.001]. Conclusions Comorbidities are more closely linked with PoRCs than OSA severity. In patients without comorbidity, PoRCs are associated with OSA severity and usually occur within the first 2 hours after the intervention.
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Pediatric obstructive sleep apnea. Int Anesthesiol Clin 2022; 60:66-73. [DOI: 10.1097/aia.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Can pediatric sleep questions be incorporated into a risk model to predict respiratory complications following adenotonsillectomy? Int J Pediatr Otorhinolaryngol 2022; 153:111015. [PMID: 34973525 DOI: 10.1016/j.ijporl.2021.111015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/02/2021] [Accepted: 12/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adenotonsillectomy, one of the most frequent surgical procedures in children, is usually performed for sleep-disordered breathing, a disease spectrum from primary snoring to obstructive sleep apnea. Children undergoing an adenotonsillectomy may be at risk for perioperative respiratory complications, necessitating intervention or escalation of care. However, there is no effective preoperative screening or risk-stratification model for perioperative respiratory complications that incorporates not only clinical history and physical examination but also sleep question responses for children as there is for adults. OBJECTIVES The aim of this prospective observational study was to develop a risk-stratification model for perioperative respiratory complications in children undergoing an adenotonsillectomy incorporating not only clinical history and physical examination but also sleep question responses. METHODS A 25-question sleep questionnaire was prospectively administered preoperatively for 1895 children undergoing an adenotonsillectomy from November 2015 to December 2017. The primary outcome measure was overall perioperative respiratory complications, collected prospectively and defined as having at least one major or minor complication intraoperatively or postoperatively. RESULTS The incidence of overall perioperative respiratory complications was 20.4%. Preoperative factors associated with perioperative respiratory complications in the multiple regression model were age, race, preoperative tonsil size, the presence of a syndrome, and the presence of a pulmonary disease. None of the sleep questionnaire responses remained in the multivariable analysis. The area under the ROC curve for the risk stratification model incorporating sleep question responses was only 0.6114% (95% CI: 0.60, 0.67). CONCLUSION Preoperative sleep question responses may be unable to predict overall perioperative respiratory complications in children undergoing an adenotonsillectomy. A robust risk stratification model incorporating sleep question responses with clinical history and physical examination was unable to discriminate or predict perioperative respiratory complications in our population undergoing an adenotonsillectomy.
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Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond. CHILDREN 2021; 8:children8110944. [PMID: 34828657 PMCID: PMC8623402 DOI: 10.3390/children8110944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
Obstructive sleep apnea (OSA) is an increasingly recognized disorder with a reported incidence of 5.7% in children. Tonsillectomy (with or without adenoidectomy) in pediatric OSA in otherwise healthy non-obese children has a success rate of approximately 75%. However, the cure rate reported for all children undergoing tonsillectomy varies from 51% to 83%. This article reviews the history of tonsillectomy, its indications, techniques, various methods, risks, and successes. The article also explores other surgical options in children with residual OSA post-tonsillectomy.
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Caetta A, Timashpolsky A, Tominaga SM, D'Souza N, Goldstein NA. Postoperative respiratory complications after adenotonsillectomy in children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2021; 148:110835. [PMID: 34280801 DOI: 10.1016/j.ijporl.2021.110835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/20/2021] [Accepted: 07/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Children with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) < 24 on overnight PSG can be safely discharged on the same day of surgery. METHODS Case series with chart review of children age <18 years with positive PSG (AHI > 2) who underwent adenotonsillectomy (T&A) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated. RESULTS Of the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2-145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but <24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae. CONCLUSIONS This study demonstrates a low risk of respiratory complications after T&A. Otherwise healthy children age ≥3 years with AHI <24 may be considered for ambulatory discharge.
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Affiliation(s)
- Alfonso Caetta
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Alisa Timashpolsky
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Stephanie M Tominaga
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
| | - Neeta D'Souza
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA. neeta.d'
| | - Nira A Goldstein
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, 450 Clarkson Avenue MSC 126, Brooklyn, NY, 11203, USA.
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Radhakrishnan D, Knight B, Gozdyra P, Katz SL, Maclusky IB, Murto K, To TM. Geographic disparities in performance of pediatric polysomnography to diagnose obstructive sleep apnea in a universal access health care system. Int J Pediatr Otorhinolaryngol 2021; 147:110803. [PMID: 34198156 DOI: 10.1016/j.ijporl.2021.110803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/14/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diagnostic polysomnography (PSG) is recommended prior to adenotonsillectomy (AT) for children with obstructive sleep apnea (OSA) and certain high-risk characteristics, but resource limitations often prevent this practice. OBJECTIVE We performed a population-based assessment of children across Ontario, Canada to describe and quantify disparities in PSG. METHODS AND MATERIALS This retrospective cohort study was performed using provincial health administrative data held at ICES. We identified children 0-10 years old who underwent PSG and AT between 2009 and 2018, and those with a PSG within 18 months prior to and/or 12 months following AT. We calculated the odds of PSG prior to/following AT after adjustment for demographics, medical comorbidities, geographic and socioeconomic characteristics. Our main predictor was driving time/distance to the nearest pediatric sleep centre ascertained using spatial analysis and geographic information systems. RESULTS We identified 27,837 children <10 years old who underwent AT for OSA in Ontario. Only 12.8% had a PSG within 18 months prior and 5.7% had a PSG within 12 months following AT. Shorter driving time/distance, older age, male sex and certain comorbidities were associated with increased odds of PSG. CONCLUSION Only a small proportion of children in our cohort underwent PSG prior to or following AT surgery despite universal access to healthcare. This study suggests a need to increase overall PSG access, particularly for those living distant from existing pediatric sleep centres. Future studies could determine if increased PSG testing in 'underserviced areas' would reduce overall surgery rates and/or improve health outcomes.
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Affiliation(s)
- D Radhakrishnan
- Children's Hospital of Eastern Ontario Research Institute, ON, Canada; Department of Pediatrics, University of Ottawa, ON, Canada; ICES, Ontario, Canada.
| | | | | | - S L Katz
- Children's Hospital of Eastern Ontario Research Institute, ON, Canada; Department of Pediatrics, University of Ottawa, ON, Canada
| | - I B Maclusky
- Children's Hospital of Eastern Ontario Research Institute, ON, Canada; Department of Pediatrics, University of Ottawa, ON, Canada
| | - K Murto
- Children's Hospital of Eastern Ontario Research Institute, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - T M To
- ICES, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, ON, Canada; Child Health Evaluative Sciences, Hospital for Sick Children, ON, Canada
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Baijal RG, Wyatt KE, Shittu T, Chen EY, Wei EZ, Tan CJ, Lee M, Mehta DK. Surgical Techniques for Tonsillectomy and Perioperative Respiratory Complications in Children. Otolaryngol Head Neck Surg 2021; 166:373-381. [PMID: 34058915 DOI: 10.1177/01945998211015176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. STUDY DESIGN The study was a retrospective cohort study. SETTING Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. METHODS Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. RESULTS A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. CONCLUSION Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique.
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Affiliation(s)
- Rahul G Baijal
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Karla E Wyatt
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Teniola Shittu
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | | | - Eric Z Wei
- Baylor College of Medicine, Houston, Texas, USA
| | | | - Maxwell Lee
- Baylor College of Medicine, Houston, Texas, USA
| | - Deepak K Mehta
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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17
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Pehora C, Faraoni D, Obara S, Amin R, Igbeyi B, Al-Izzi A, Sayal A, Sayal A, Mc Donnell C. Predicting Perioperative Respiratory Adverse Events in Children With Sleep-Disordered Breathing. Anesth Analg 2021; 132:1084-1091. [PMID: 33002926 DOI: 10.1213/ane.0000000000005195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia. METHODS Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs. RESULTS In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05-2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03-1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09-2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11-2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33-4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79-5.14; P < .001) were associated with PRAEs. CONCLUSIONS We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation.
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Affiliation(s)
- Carolyne Pehora
- From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Faraoni
- From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Soichiro Obara
- Department of Anesthesia, Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brenda Igbeyi
- Department of Family Medicine, Labrador South Health Centre, Labrador-Grenfell Regional Health, Forteau, Newfoundland, Canada
| | - Adel Al-Izzi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Aman Sayal
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aarti Sayal
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Conor Mc Donnell
- From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. S1-Leitlinie: Obstruktive Schlafapnoe im Rahmen von Tonsillenchirurgie mit oder ohne Adenotomie bei Kindern – perioperatives Management. SOMNOLOGIE 2021. [DOI: 10.1007/s11818-021-00303-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. [German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]. HNO 2020; 69:3-13. [PMID: 33354732 DOI: 10.1007/s00106-020-00970-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.
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Affiliation(s)
- G Badelt
- Klinik für Anästhesie und Kinderanästhesie, Krankenhaus Barmherzige Brüder Regensburg, Klinik St. Hedwig, Steinmetzstraße 1-3, 93049, Regensburg, Deutschland. .,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland.
| | - C Goeters
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - K Becke-Jakob
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - T Deitmer
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - C Eich
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - C Höhne
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - B A Stuck
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - A Wiater
- Kinder- und Jugendmedizin/Schlafmedizin, Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)
- Arbeitsgruppe Pädiatrie im Konvent der Deutschen Gesllschaft für Kinder- und Jugendmedizin, Schwalmstadt-Treysa, Deutschland
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Lavin JM, Sawardekar A, Sohn L, Jones RC, Fusilero L, Iafelice ME, Molenda L. Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach. Laryngoscope 2020; 131 Suppl 1:S1-S10. [PMID: 32438522 DOI: 10.1002/lary.28760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN Quality improvement initiative. METHODS Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE N/A Laryngoscope, 131:S1-S10, 2021.
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Affiliation(s)
- Jennifer M Lavin
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Amod Sawardekar
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Lisa Sohn
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Roderick C Jones
- Department of Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laurely Fusilero
- Center for Excellence, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Mary E Iafelice
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laura Molenda
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
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Moroco AE, Saadi RA, Wilson MN. Post-tonsillectomy respiratory complications in children with sleep disordered breathing. Int J Pediatr Otorhinolaryngol 2020; 131:109852. [PMID: 31901486 DOI: 10.1016/j.ijporl.2019.109852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population. METHODS Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected. RESULTS A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023). CONCLUSION A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.
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Affiliation(s)
- Annie E Moroco
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Robert A Saadi
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.
| | - Meghan N Wilson
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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22
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Ekstein M, Zac L, Schvartz R, Goren O, Weiniger CF, DeRowe A, Fishman G. Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:292-300. [PMID: 31587265 DOI: 10.1111/aas.13488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/21/2019] [Accepted: 09/22/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. METHODS Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. RESULTS During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. CONCLUSIONS Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.
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Affiliation(s)
- Margaret Ekstein
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Lilach Zac
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Reut Schvartz
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Or Goren
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Carolyn F. Weiniger
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Ari DeRowe
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Pediatric Otolaryngology Unit Tel Aviv Medical Center Dana-Dwek Children’s Hospital Tel Aviv Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Gad Fishman
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Pediatric Otolaryngology Unit Tel Aviv Medical Center Dana-Dwek Children’s Hospital Tel Aviv Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
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Ohn M, Eastwood P, von Ungern-Sternberg BS. Preoperative identification of children at high risk of obstructive sleep apnea. Paediatr Anaesth 2020; 30:221-231. [PMID: 31841240 DOI: 10.1111/pan.13788] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 12/24/2022]
Abstract
Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well-known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so. Currently, there is no standardized approach to the best method of preoperative screening for obstructive sleep apnea. Focused history, clinical assessments, and knowledge regarding the strengths and limitations of available obstructive sleep apnea assessment tools will help recognize a child with obstructive sleep apnea in the preoperative setting.
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Affiliation(s)
- Mon Ohn
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia
| | - Peter Eastwood
- Centre for Sleep Science, School of Human Sciences, The University of Western Australia, Crawley, WA, Australia.,West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Britta S von Ungern-Sternberg
- Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia
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24
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Allen DZ, Worobetz N, Lukens J, Sheehan C, Onwuka A, Dopirak RM, Chiang T, Elmaraghy C. Outcomes intensive care unit placement following pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2020; 129:109736. [PMID: 31704575 DOI: 10.1016/j.ijporl.2019.109736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. METHODS This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. RESULTS There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. CONCLUSIONS This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.
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Affiliation(s)
- David Z Allen
- The Ohio State College of Medicine, Columbus, OH, USA
| | - Noah Worobetz
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Cameron Sheehan
- The Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Amanda Onwuka
- The Center for Surgical Outcomes and Research, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Tendy Chiang
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Elmaraghy
- The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 271] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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26
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Pediatric obstructive sleep apnea screening questionnaire and post-operative outcomes: A prospective observational study. Int J Pediatr Otorhinolaryngol 2019; 127:109661. [PMID: 31476606 DOI: 10.1016/j.ijporl.2019.109661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/25/2019] [Accepted: 08/25/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Obstructive Sleep Apnea (OSA) and Sleep Disordered Breathing (SDB) in children tend to be a more complex and multifactorial disease than in adults. Although adult screening tools, such as the STOP-BANG questionnaire, their application limited in pediatrics. We used our previously described 6-point questionnaire to identify OSA in children and evaluated its use for predicting post-operative respiratory events. METHODS Children from 3 to 18 years of age presenting for surgery were eligible. Exclusion criteria were emergency surgery or refusal to participate. A 6-question survey regarding symptoms of OSA/SDB was administered preoperatively. Neck circumference was measured. Height and weight were recorded from preoperative data and the body mass index (BMI) percentile obtained. RESULTS 749 patients were enrolled in the study. 707 patients were in the final analysis (359 boys and 348 girls, mean age 12 ± 4 years). The median 6-item questionnaire score was 1 (interquartile range: 0, 2) and 186 (26%) scored ≥ 2 of 6 points. Children with predicted OSA (yes on ≥ 2 questions) were more likely than without predicted OSA to require supplemental oxygen in the PACU (24% vs. 17%; 95% confidence interval [CI] of difference: -0.3%, 13%; p = 0.049). Amongst 681 patients with available data on Post Anesthesia Care Unit (PACU) length of stay (LOS), prolonged LOS (>1 h) was not more likely among children with predicted OSA (42%) compared to those without predicted OSA (39%; 95% CI of difference: -5%, 11%; p = 0.479). Outcomes assessed after PACU discharge noted no differences. Specifically, overnight hospital stay was required in 33% of patients with predicted OSA as compared to 29% of those without (95% CI of difference: -4%, 11%; p = 0.399). On POD 0, supplemental oxygen was used on the inpatient ward for 6% of patients with predicted OSA compared to 4% of patients without predicted OSA (95% CI of difference: -2%, 6%; p = 0.272). CONCLUSION The incidence of OSA/SDB is under-appreciated in children presenting for non-otolaryngological surgical procedures. Although patients judged to have OSA on the 6-item question may need for supplemental oxygen longer in the PACU, no other outcomes differences were noted.
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27
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Goldstein NA, Friedman NR, Nardone HC, Aljasser A, Tobey ABJ, Don D, Baroody FM, Lam DJ, Goudy S, Ishman SL, Arganbright JM, Baldassari C, Schreinemakers JBS, Wine TM, Ruszkay NJ, Alammar A, Shaffer AD, Koempel JA, Weedon J. The Generalizability of the Clinical Assessment Score-15 for Pediatric Sleep-Disordered Breathing. Laryngoscope 2019; 130:2256-2262. [PMID: 31782808 DOI: 10.1002/lary.28428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 10/09/2019] [Accepted: 11/02/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion. METHODS Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15. RESULTS Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1. CONCLUSION This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing. LEVEL OF EVIDENCE 2B Laryngoscope, 130:2256-2262, 2020.
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Affiliation(s)
- Nira A Goldstein
- Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Norman R Friedman
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado
| | - Heather C Nardone
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Abdullah Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Allison B J Tobey
- Division of Pediatric Otolaryngology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh
| | - Debra Don
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Fuad M Baroody
- Section of Otolaryngology-Head and Neck Surgery, The University of Chicago Medicine and Comer Children's Hospital, Chicago, Illinois
| | - Derek J Lam
- Division of Pediatric Otolaryngology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon
| | - Steven Goudy
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Stacey L Ishman
- Division of Pediatric Otolaryngology-Head and Neck Surgery and Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jill M Arganbright
- Department of Pediatric Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri
| | - Cristina Baldassari
- Department of Otolaryngology, Children's Hospital of The King's Daughters, Norfolk, Virginia, U.S.A
| | - J B S Schreinemakers
- Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Todd M Wine
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado
| | - Nicole J Ruszkay
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ahmed Alammar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh
| | - Jeffrey A Koempel
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Jeremy Weedon
- Research Division, State University of New York Downstate Medical Center, Brooklyn, New York
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28
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Katz SL, Monsour A, Barrowman N, Hoey L, Bromwich M, Momoli F, Chan T, Goldberg R, Patel A, Yin L, Murto K. Predictors of postoperative respiratory complications in children undergoing adenotonsillectomy. J Clin Sleep Med 2019; 16:41-48. [PMID: 31957650 DOI: 10.5664/jcsm.8118] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is commonly treated with adenotonsillectomy (AT), bringing risk of perioperative respiratory adverse events (PRAEs). We aimed to concurrently identify clinical and polysomnographic predictors of PRAEs in children undergoing AT. METHODS Retrospective study of children undergoing AT at a tertiary-care pediatric hospital, with prior in-hospital polysomnography, January 2010 to December 2016. PRAEs included those requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Relationships of PRAEs to preoperative comorbidities or polysomnography results were examined with univariable logistic regression. Variables with P < .1 and age were included in backward stepwise multivariable logistic regression. Predictive performance (area under the curve, AUC) was validated with bootstrap resampling. RESULTS Analysis included 374 children, median age 6.1 years; 286 (76.5%) had ≥ 1 comorbidity. 344 (92.0%) had sleep-disordered breathing; 232 (62.0%) moderate-severe; 66 (17.6%) had ≥ 1 PRAE. PRAEs were more frequent in children with craniofacial, genetic, cardiac, airway anomaly, or neurological conditions, AHI ≥ 5 events/h and oxygen saturation nadir ≤ 80% on preoperative polysomnography. Prediction modeling identified cardiac comorbidity (odds ratio [OR] 2.09 [1.11, 3.89]), airway anomaly (OR 3.19 [1.33, 7.49]), and younger age (OR < 3 years: 4.10 (1.79, 9.26; 3 to 6 years: 2.21 [1.18, 4.15]) were associated with PRAEs (AUC 0.74; corrected AUC 0.68). CONCLUSIONS Prediction modeling concurrently evaluating comorbidities and polysomnography metrics identified cardiac disease, airway anomaly, and young age as independent predictors of PRAEs. These findings suggest that medical comorbidity and age are more important factors in predicting PRAEs than PSG metrics in a medically complex population.
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Affiliation(s)
- Sherri L Katz
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Lynda Hoey
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Matthew Bromwich
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Theodora Chan
- McMaster University, School of Physiotherapy, Hamilton, Ontario, Canada
| | - Reuben Goldberg
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Abhilasha Patel
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Li Yin
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Kimmo Murto
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Anesthesia, Ottawa, Ontario, Canada
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29
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Lavin JM, Smith C, Harris ZL, Thompson DM. Critical care resources utilized in high-risk adenotonsillectomy patients. Laryngoscope 2018; 129:1229-1234. [PMID: 30582170 DOI: 10.1002/lary.27623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. METHODS A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2-hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. RESULTS One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). CONCLUSION Most high-risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1229-1234, 2019.
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Affiliation(s)
- Jennifer M Lavin
- Division of Pediatric Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Ann and Robert H. Lurie Children's Hospital of Chicago; the Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Craig Smith
- Division of Pediatric Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Zena Leah Harris
- Division of Pediatric Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Ann and Robert H. Lurie Children's Hospital of Chicago; the Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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30
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Saur JS, Brietzke SE. Response to Letter to the Editor regarding article titled "Polysomnography results versus clinical factors to predict postoperative respiratory complications following pediatric adenotonsillectomy". Int J Pediatr Otorhinolaryngol 2018; 105:189-190. [PMID: 29273274 DOI: 10.1016/j.ijporl.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John S Saur
- Walter Reed National Military Medical Center, Bethesda, MD 20889, United States
| | - Scott E Brietzke
- Joe DiMaggio Children's Hospital at Memorial, Hollywood, FL 33021, United States; Walter Reed National Military Medical Center, Bethesda, MD 20889, United States.
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Hsueh WY, Lee CF, Lee CH, Kang KT. Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2018; 105:187-188. [PMID: 29233563 DOI: 10.1016/j.ijporl.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/04/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Wan-Yi Hsueh
- Department of Otolaryngology, Hsinchu Cathay General Hospital, Hsinchu, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Yuanpei University of Medical Technology, Department of Biomedical Engineering, Hsinchu, Taiwan
| | - Chia-Fan Lee
- Speech Language Pathologist, Child Developmental Assessment and Intervention Center, Taipei City Hospital, Taipei, Taiwan
| | - Chia-Hsuan Lee
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kun-Tai Kang
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan.
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Reckley LK, Fernandez-Salvador C, Camacho M. The effect of tonsillectomy on obstructive sleep apnea: an overview of systematic reviews. Nat Sci Sleep 2018; 10:105-110. [PMID: 29670412 PMCID: PMC5894651 DOI: 10.2147/nss.s127816] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Tonsillectomy with adenoidectomy is a combination surgery that has been used to treat pediatric obstructive sleep apnea (OSA). For adults, tonsillectomy has also been reported as a primary treatment modality when the tissue is hypertrophied. The objective of this study is to provide an overview of published systematic reviews and meta-analyses of tonsillectomy with or without adenoidectomy as used in the treatment of OSA in children and adults. DATA SOURCES Nine databases, including PubMed/MEDLINE. REVIEW METHODS Databases were searched from their inception through July 9, 2017. The PRISMA statement was followed. RESULTS More than 20 recent systematic reviews and meta-analyses were identified regarding tonsillectomy as a treatment modality for OSA. There were four articles that addressed tonsillectomy's overall success, efficacy, and complications in otherwise healthy pediatric patients. Three studies evaluated tonsillectomy in obese children, and two specifically examined children with Down syndrome. Only one systematic review and meta-analysis discussed tonsillectomy as a treatment for OSA in the adult population. CONCLUSION Tonsillectomy as an isolated treatment modality is rarely performed in pediatric patients with OSA; however, tonsillectomy is commonly performed in combination with adenoidectomy and the combination has demonstrated efficacy as the primary treatment option for most children. In the limited adult data, tonsillectomy alone for OSA has a surprising success rate; yet, more research is required to determine long-term improvement and need for further treatment.
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Affiliation(s)
- Lauren K Reckley
- Otolaryngology - Head and Neck Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | | | - Macario Camacho
- Otolaryngology - Head and Neck Surgery, Tripler Army Medical Center, Honolulu, HI, USA
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