Clinical characteristics of obstructive sleep apnea versus infectious adenotonsillar hyperplasia in children

Clinical Impact of Preoperative Tonsil and Adenoid Size on Symptomatic Outcomes Following Adenotonsillectomy in Pediatric Patients

Background Adenotonsillar hypertrophy is a common clinical problem in pediatric patients. Adenotonsillectomy is a surgical intervention to remove airway obstruction and alleviate symptoms. However, some children continue to experience persistent symptoms after surgery. Objective This study aimed to investigate the relationship between preoperative tonsils and adenoid size and the persistence of symptoms, including snoring, mouth breathing, noisy breathing, and sleep apnea, after adenotonsillectomy in pediatric patients. Method This study was conducted in Taif, Saudi Arabia, and included 109 pediatric patients aged three to 14 years who underwent adenotonsillectomy. Data on preoperative and postoperative symptoms were collected through patient records and follow-up surveys. Tonsil and adenoid size were assessed using the Brodsky scale and endoscopic grading scales, respectively. Statistical analysis was performed using SPSS Version 26 (IBM Corp., Armonk, NY). Results The most prevalent presenting symptoms were snoring, mouth breathing, and noisy breathing. Tonsil size grades 3+ and 4+ were significantly more prevalent than the other grades (p<0.05). Adenoid size grades 3 and 4 were also significantly more prevalent than the other grades (p<0.05). Significant associations were observed between tonsil and adenoid size grades and specific presenting symptoms, such as snoring, mouth breathing, and noisy breathing. No significant correlations were found between preoperative tonsil or adenoid size and postoperative persistent symptoms. Conclusion While tonsil and adenoid size are essential factors in determining the need for surgery, they may not predict postoperative resolution of symptoms. A comprehensive evaluation of various clinical factors is necessary to understand the persistence of symptoms after surgery. Although adenotonsillectomy is an effective treatment for upper airway obstruction in pediatric patients, some individuals may experience residual symptoms.

The impact of mouth breathing on dentofacial development: A concise review

Mouth breathing is one of the most common deleterious oral habits in children. It often results from upper airway obstruction, making the air enter completely or partially through oral cavity. In addition to nasal obstruction caused by various kinds of nasal diseases, the pathological hypertrophy of adenoids and/or tonsils is often the main etiologic factor of mouth breathing in children. Uncorrected mouth breathing can result in abnormal dental and maxillofacial development and affect the health of dentofacial system. Mouth breathers may present various types of growth patterns and malocclusion, depending on the exact etiology of mouth breathing. Furthermore, breathing through the oral cavity can negatively affect oral health, increasing the risk of caries and periodontal diseases. This review aims to provide a summary of recent publications with regard to the impact of mouth breathing on dentofacial development, describe their consistencies and differences, and briefly discuss potential reasons behind inconsistent findings.

Hemorrhage after adenotonsillectomy in children: tertiary center experiences

BACKGROUND

Adenotonsillectomy is the most commonly performed surgery in the pediatric population. Hemorrhage after adenotonsillectomy, which can occur at any time postoperatively, is one of the most serious complications.

OBJECTIVE

To determine the frequency of hemorrhage in children after adenotonsillectomy and to compare postoperative hemorrhage with regard to age and sex.

METHODS

A cross-sectional longitudinal study was conducted at the Ear, Nose, and Throat Clinic, University Clinical Center Tuzla, and included all children of both sexes, aged 3 to 15 years, who underwent adenotonsillectomy during a 1.5-year period.

RESULTS

A total of 201 children aged 3-15 years underwent adenotonsillectomy, 113 males and 88 females, which corresponds to a ratio of 1.28: 1. Adenotonsillectomy was performed in 147 (73.1%) patients and adenoidectomy in 54 (27%). In the overall sample, there were 19 (9.5%) subjects with postoperative hemorrhage. Primary hemorrhage occurred in 9 subjects (47%) and secondary hemorrhage in 10 subjects (53%). Significantly more female subjects had postoperative hemorrhage. In the group of subjects with hemorrhage, the mean age (standard deviation) was 8.45 (3.3) years. Tonsillar lodges are common sites of hemorrhage.

CONCLUSION

The frequency and causes of hemorrhage after adenotonsillectomy in our study are partially comparable to the world data.

Paediatric tonsillectomy and adenotonsillectomy in a rural setting: a retrospective study over a period of 6-years

BACKGROUND

Swan Hill District Health (SHDH) provides Otolaryngological services to outer regional Victoria. A preoperative checklist determines eligibility for tonsillectomy, and the role of preoperative investigations such as oximetry. Visiting specialists who provide T&A also remain on-site for 24 h post-surgery. Management of post-discharge complications is supported by SHDH's Emergency Department. Unstable patients are transferred to tertiary care hospitals. This study examines the safety outcomes associated with rural Tonsillectomy and adenotonsillectomy (T&A) and the impact of peri-operative protocols on these outcomes.

METHODS

This is a retrospective cohort study of all paediatric (2-18 years old) patients undergoing T&A from August 2014 to June 2020 at SHDH. Four external hospital databases which accept patient transfers from SHDH were searched for T&A-related complications. The primary outcome was complication incidence. Secondary outcomes were length of stay, and rates of hospital readmissions, return to theatre and inter-hospital transfer.

RESULTS

Two hundred and four patients were included, with median age 6 years old; 68.1% (n = 139/204) had obstructive sleep apnoea, or sleep disordered breathing, wherein 36.0% (n = 50/139) had documented evidence of normal/inconclusive oximetry. The complication rate is 6.9% (n = 14/204), with two intraoperative, five perioperative and seven post-discharge complications. All intra- and peri-operative complications were managed locally. All post-discharge complications presented to outer regional EDs. Two patients required inter-hospital transfer for monitoring of post-tonsillectomy bleeds in a specialist unit.

CONCLUSIONS

Patients who pass a preoperative risk checklist can safely undergo T&A in selected rural settings which adhere to strict patient selection criteria and implement safety measures to address complications.

Sleep Disordered Breathing and Recurrent Tonsillitis Are Associated With Polymicrobial Bacterial Biofilm Infections Suggesting a Role for Anti-Biofilm Therapies

Background

The underlying pathogenesis of pediatric obstructive sleep disordered breathing (SDB) and recurrent tonsillitis (RT) are poorly understood but need to be elucidated to develop less invasive treatment and prevention strategies.

Methods

Children aged between 1- and 16-years undergoing adenoidectomy, tonsillectomy or adenotonsillectomy for SDB (n=40), RT alone (n=18), or both SDB and RT (SDB+RT) (n=17) were recruited with age-matched healthy controls (n=33). Total bacterial load and species-specific densities of nontypeable Haemophilus influenzae (NTHi), Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae and Moraxella catarrhalis were measured by qPCR in nasopharyngeal swabs, oropharyngeal swabs, adenoid and tonsillar tissue from children with SDB, SDB+RT and RT, and in naso- and oro- pharyngeal swabs from healthy children. A subset of tonsil biopsies were examined for biofilms using 16S rRNA FISH (n=3/group).

Results

The 5 bacterial species were detected in naso- and oro- pharyngeal samples from all children. These species were frequently detected in adenotonsillar tissue (except S. aureus, which was absent in adenoids) from children with SDB, SDB+RT and RT. NTHi and S. aureus were observed in tonsils from 66.7-88.2% and 33.3-58.8% of children respectively. Similar total and species-specific bacterial densities were observed in adenotonsillar tissue from children with SDB, SDB+RT or RT. Nasopharyngeal and oropharyngeal swabs were more likely to have multiple bacterial species co-detected than adenotonsillar tissue where one or two targeted species predominated. Polymicrobial biofilms and intracellular bacteria were observed in tonsils from children with adenotonsillar disease.

Conclusions

Antimicrobials, particularly anti-biofilm therapies, may be a strategy for managing children with SDB.

Effect of tonsillectomy on antibiotic prescribing in children

INTRODUCTION

Tonsillectomy is the second most common surgical procedure performed in pediatric otolaryngology. Multiple courses of antibiotics are usually prescribed prior to surgical intervention. Surgery is indicated when patients reach a certain number of infective episodes, or their obstructive symptoms warrant intervention. Little is known about the role of tonsillectomy on long term postoperative antibiotic use. Recently, our group published a retrospective case series that described the clinical characteristics and outcomes of children under the age of 16 years who underwent tonsillectomy. This study is a follow-up on this previous case series and its purpose is to determine whether tonsillectomy in this group of children led to a reduction in the number of antibiotics prescribed in the year following surgery.

METHODS

Data were collected from the clinical records departments of two district health boards in Auckland, New Zealand. Hospital morbidity records were reviewed for all children younger than 16 years old, who underwent a tonsillectomy between December 2015 and December 2017 in the Auckland region. All antibiotics prescribed following surgery were obtained from New Zealand's national community prescribing database.

RESULTS

A total of 1538 children underwent tonsillectomy during the study period. Following surgery, antibiotics were prescribed to 828 (54%) patients at the time of discharge, with an average of 1.2 ± 0.1 courses in the year following surgery. This was significantly reduced compared to preoperative antibiotic intake (3.4 ± 0.1 courses) in the year preceding surgery (p < 0.001). Readmission within 30 days of discharge was not associated with increased antibiotic usage postoperatively. In the two weeks following surgery, 25% of patients were prescribed a course of antibiotics for a presumed postoperative infection.

CONCLUSIONS

These findings support the benefit of tonsillectomy in reducing antibiotic consumption in the year following surgery. Furthermore, it has highlighted areas of practice, such as perioperative antibiotic prescription, which can be improved to further reduce the prescription of antibiotics for children with tonsillar hyperplasia.

Mean platelet volume levels in children with sleep-disordered breathing: a meta-analysis

BACKGROUND

Pediatric sleep-disordered breathing (SDB) correlated with respiratory conditions of snoring and hypopnea. Mean platelet volume (MPV) was an inflammatory marker, related to increased inflammatory condition of pediatric patients. Increase of MPV level may cause failure to thrive or increased upper airway infection rate. The aim of this study was to perform systematic review and meta-analysis to investigate the difference on MPV values for pediatric SDB, and compare the change on MPV after surgery in patients with pediatric SDB.

METHODS

A systemic review of the studies from PubMed, EMBASE, and Cochrane Library databases was conducted in March 2020, supported by reviewing of published articles for studies comparing MPV in pediatric SDB. Meta-analysis was used to compare the change of MPV in pediatric SDB, and sub-group analysis was also used to compare the MPV decrease after surgeries of adenoidectomy or adenotonsillectomy.

RESULTS

There were seven studies included in the review. Six of them including 963 subjects showed that a significant increase of MPV was noted in pediatric SDB compared to those in pediatric non-SDB (P < 0.05). Total standardized mean difference (SMD) in MPV between pediatric SDB and non-SDB was 0.51 (95% CI =0.30-0.72, P < 0.05). A significant decrease of MPV was found in pediatric SDB patients who underwent surgery (total SMD = - 0.36; 95% CI = - 0.70- -0.02, P < 0.05). Decreases of MPV after adenoidectomy and adenotonsillectomy were observed, but only the effect of adenotonsillectomy had a statistical significance (total SMD = - 0.72; 95% CI = - 1.18 - -0.26, P < 0.05).

CONCLUSION

The MPV was significantly higher in patients with pediatric SDB, indicating the presence of increased platelet activity in pediatric SDB patients. The level of MPV could be reduced by the two surgeries, especially adenotonsillectomy.

Inflammation, infection, and allergy of upper airways: new insights from national and real-world studies

The upper airways (UA) should be considered as a functional unit. Current functional anatomy divides URT in three, mutually dependent, "junction boxes": i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). Correct ventilation and effective mucociliary clearance of these sites significantly affect the healthy physiology of the entire respiratory system. The OMC, SER, and RP obstruction is the first pathogenic step in the inflammatory/infectious cascade of UA disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for airway obstruction. Moreover, bacterial biofilm (a strategy modality of bacterial survival) is an important local cause of systemic antibiotic ineffectiveness, recurrent infections, and antibiotic resistance. Health microbiota guarantees UA wellness; on the contrary, dysbiosis promotes and worsens UA infections. Allergy, namely type 2 inflammation, is a common cause of UA obstruction such as promoting in turn infections. Fiberoptic endoscopy is a mandatory diagnostic tool in clinical practice. Nasal cytology, mainly concerning flow cytometry, allows defining rhinitis phenotypes so allowing a precision medicine approach. Several conventional therapeutic approaches are available, but efficacy and safety should be ever properly considered before the prescription. Also, complementary medicine plays a fruitful role in the management of UA diseases. National and real-world studies are reported and discussed as they may be useful in daily clinical practice.

Risk factors for children requiring adenotonsillectomy and their impact on postoperative complications: a retrospective analysis of 2000 patients

Adenotonsillectomies are commonly performed procedures and sleep-disordered breathing is becoming increasingly important as an indication for surgery. Because of the higher risks in patients with obstructive sleep apnoea, the required level of postoperative care for these patients is currently under discussion, and better identification of patients at risk may reduce unnecessary postoperative monitoring. To evaluate the influence of obstructive sleep apnoea, and other risk factors, on peri-operative complications in children requiring adenotonsillectomy, we performed a retrospective case-control study that included 1995 patients treated between January 2009 and June 2017. In our analysis, young age (OR 3.8, 95%CI 2.1-7.1), low body weight (OR 2.6, 95%CI 1.5-4.4), obstructive sleep apnoea (OR 2.4, 95%CI 1.5-3.8), pre-existing craniofacial or syndromal disorders (OR 2.3, 95%CI 1.4-3.8) and adenotonsillectomy, compared with adenoidectomy alone, (OR 7.9, 95%CI 4.7-13.1) were identified as risk factors for complications during or after surgery, p < 0.001. All 13 patients suffering from complications more than 3 h postoperatively had obstructive sleep apnoea plus at least one more of these risk factors. Patients at risk of postoperative complications can therefore be identified by several criteria pre-operatively, and should be monitored postoperatively using pulse oximetry overnight. For all other patients, postoperative observation on a surgical ward without extra monitoring is sufficient. Admission to paediatric intensive care should be reserved for patients suffering serious intra-operative complications.

Paediatric Posttonsillectomy Haemorrhage Rates in Auckland: A Retrospective Case Series

Background

Tonsillectomy is one of the most commonly performed surgical procedures in children. It is performed for sleep-disordered breathing and infective symptoms. Despite advances in instrumentation and perioperative care, posttonsillectomy haemorrhage (PTH) remains a significant complication, which should be audited regularly.

Methods

A retrospective case series of all tonsillectomies performed in patients <15 years old in the Auckland region during 2017 was performed. Demographic, clinical, and surgical data were extracted and analysed. Univariate analysis was performed to compare patients with and without PTH.

Results

A total of 2177 tonsillectomies were performed during the study period, 64% in a public hospital and 36% in a private hospital. The overall PTH rate was 3.6% (0.23% occurring within the first 24 hours (primary) and 3.4% after 24 hours (secondary)). Mean time to PTH was 6.6 ± 3 days (range: 1-16 days). 90% of PTH occurred within the first 10 days and 99% by 14 days. Return to theatre was required in 28% of these cases, representing 1% of all tonsillectomies. There were no deaths or major complications in this cohort. The only differences observed between patients with PTH and those without were that children with PTH had smaller tonsils (p=0.004) and were less likely to have associated OME (p<0.001).

Conclusion

It is important to report institutional tonsillectomy outcomes and associated complications. These results show that PTH rates in Auckland remain within acceptable limits according to the literature.