Persistencia a largo plazo del síndrome de la apnea-hipopnea obstructiva del sueño infantil tratada con adenoamigdalectomía. Análisis de factores pronósticos

Surgical versus non-surgical treatment in the Obstructive Sleep Apnea-Hypopnea Syndrome

INTRODUCTION

The treatment of choice for pediatric OSAHS is surgical. However, its etiopathogenesis is multifactorial and surgery does not always solve it. Therefore, other modalities of treatment are used. The main objective of this study is to shed light on the efficacy of surgery compared to other treatments.

METHODS AND MATERIALS

Prospective cohort study with 317 children ages 1-13 years and apnea-hypopnea index (AHI) ≥3/h with no previous treatment. The treatment was organised into 3 categories: surgical (n = 201), medical (n = 75) and observation (n = 41). Quality of life and sleep was assessed by two validated questionnaires (PSQ & Esteller et al.) The upper airway was explored, and nocturnal polysomnography (PSG) performed in every patient. After 12 ± 3 months of treatment was completed, a new PSG and questionnaires were evaluated.

RESULTS

The surgical group improved significantly both subjectively and objectively. Mean AHI decreased from 7.95/h to 2.57/h and T 90 (time spent with arterial oxygen saturation <90%) from 0.49 to 0. AHI of the medical group decreased only from 5.09/h to 4.9/h. Subjective parameters improved less than in the surgical group. Persistence after surgery was 31%, 50% following medical treatment, and after observation 75%. There were no differences in age and BMI between groups. Age or obesity showed no relationship with treatment success or failure.

CONCLUSIONS

The best results were achieved in surgically treated children. However, 31% of those operated had OSAHS persistence, which means a combination of treatments may be the most appropriate strategy.

Outcome of drug-induced sleep endoscopy-directed surgery for persistent obstructive sleep apnea after adenotonsillar surgery

PURPOSE

Drug-induced sleep endoscopy (DISE) is suitable for evaluating persistent obstructive sleep apnea syndrome (OSAS) after adenotonsillar surgery as a means to guide surgical intervention, yet few studies demonstrate its usefulness in resolving the syndrome. We describe our experience of DISE-directed surgery in children with persistent OSAS by analysing objective and subjective outcomes of this treatment.

METHODS

Prospective study of 20 otherwise healthy 2-12 year-old children with OSAS persisting after adenotonsillar surgery. All patients underwent DISE-directed surgery and were followed up clinically and with a polysomnogram at 12 ± 3 months.

RESULTS

All 20 children had an apnea-hypopnea index (AHI) score ≥1 (mean: 6.1 ± 4.9) and 75% had AHI>3 before surgery. We performed a total of 14 total tonsillectomies (70%), 7 with associated pharyngoplasties; 5 radiofrequency turbinate reductions (25%); 7 radiofrequency lingual tonsil reductions (35%); and 10 revision adenoidectomies (50%). No surgery-related complications were observed. AHI scores at follow-up were significantly lower than AHI scores before surgery (1.895 ± 1.11 vs 6.143 ± 4.88; p < 0.05) and, in 85% (n = 17) of patients, AHI was below 3. There was a significant reduction in the number of children with AHI>3 in follow-up at 12 ± 3 months (15%; n = 3) compared to before surgery (75%; n = 15) (p < 0.005).

CONCLUSION

DISE-directed surgery for otherwise healthy children with persistent OSAS is a useful and safe technique to decide a therapeutic strategy and to obtain good objective and subjective results regarding resolution of the syndrome.

Surgical treatment for childhood obstructive sleep apnoea: Cold-knife tonsillar dissection versus bipolar radiofrequency thermal ablation

INTRODUCTION AND OBJECTIVE

Adenotonsillectomy for treatment of childhood obstructive sleep apnoea is effective. The uncomfortable postoperative period and possible complications have significantly increased the use of partial techniques, seeking to improve these aspects while achieving the same results in resolving sleep apnoea. The aim was to present the experience with 2 consecutive groups of patients, comparing total tonsillectomy to bipolar radiofrequency ablation (RFA).

METHOD

A group of 96 children that underwent total tonsilloadenoidectomy using cold dissection were compared to another group of 101 children that underwent RFA. In all cases, polysomnography was performed before and 1 year after surgery. The percentage of cases with persistent disease (apnea-hypopnea index ≥ 3) and the improvement of clinical symptoms at one year were evaluated. The percentages of surgical and anaesthetic complications in both groups were also compared.

RESULT

The persistence of the syndrome was comparable in both groups: 25% in the cold dissection and 22.77% in the radiofrequency ablation group. Anaesthetic complications (5% in the group where cold dissection was used and 4.2% in the radiofrequency ablation group) and postoperative bleeding rates were very low and statistically comparable with both techniques.

CONCLUSION

In the treatment of childhood obstructive sleep apnoea syndrome, both extracapsular surgery using cold scalpel and bipolar radiofrequency tunnelling techniques are safe. Likewise, results as to resolution of the syndrome show no statistically significant differences.

Polysomnographic findings after adenotonsillectomy for obstructive sleep apnoea in obese and non-obese children: a systematic review and meta-analysis

BACKGROUND

Use of polysomnography (PSG) is the gold standard of diagnosis and measurement of treatment effectiveness for paediatric obstructive sleep apnoea (OSA). Although adenotonsillectomy (T&A) is effective in diminishing the apnoea-hypopnoea index (AHI), a meta-analysis of postoperative changes for all other PSG parameters and outcome comparisons between obese and non-obese children following T&A have never been conducted.

OBJECTIVE OF REVIEW

To comprehensively review polysomnographic findings after surgery for obese and non-obese children with OSA.

SEARCH STRATEGY

Study protocol was registered on PROSPERO (CRD42013004737). Two authors independently searched databases including PubMed, MEDLINE, EMBASE and Cochrane Review from January 1997 to July 2014. The keywords used included the following: sleep apnea, OSA, sleep apnea syndromes, tonsillectomy, adenoidectomy, infant, child, adolescent, and Humans.

EVALUATION METHOD

A comprehensive systematic review and meta-analysis for literature for OSA children treated by T&A with polysomnography data. Random-effects model was applied to determine postoperative sleep parameter changes and the surgical success rate between obese and non-obese groups. The quality of studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

In total, 51 studies with 3413 subjects were enrolled. After surgery, sleep architecture was altered by a significant decrease in sleep stage 1, and an increase in slow-wave sleep and the rapid eye movement stage, and enhanced sleep efficiency. The mean difference between pre- and postoperative was a significant reduction of 12.4 event/h in AHI, along with a reduction of obstructive index, hypopnoea index, central index and arousal index. Mean and minimum oxygen saturation increased significantly after surgery. The overall success rate was 51% for postoperative AHI <1 (obese versus non-obese versus combined, 34% versus 49% versus 56%), and 81% for AHI <5 (obese versus non-obese versus combined, 61% versus 87% versus 84%). Meta-regression analyses demonstrate that postoperative AHI was positively correlated with AHI and body mass index z score before surgery.

CONCLUSIONS

Meta-analysis of current literature shows T&A offers prominent improvement in a variety of sleep parameters. Improvements in non-obese children exceeded those for obese children. Postoperative residual OSA remained in roughly half of the children, especially those with severe disease and obesity, making additional treatment strategies and/or long-term follow-up highly desirable.

Clinical and polysomnographic correlation in sleep-related breathing disorders in children

INTRODUCTION

Although polysomnography is the gold standard test for sleep-disordered breathing in children, there is controversy about its indication in all cases. Among the arguments both for and against is the lack of correlation between objective values and the symptoms.

OBJECTIVE

To evaluate the correlation between clinical data and apnea-hypopnoea index (AHI) in our work environment.

MATERIAL AND METHODS

We compared the preoperative clinical symptoms and AHI statistically in 170 children with sleep-disordered breathing who underwent polysomnography. We also analysed the correlation to postoperative level, with a subgroup of 80 children who underwent adenotonsillectomy with 1 year of polysomnography follow-up.

RESULTS

Before surgery, only the degree of tonsillar hypertrophy was statistically significant correlated with AHI. At post-operative follow-up, evidence of correlation between AHI and apnoea was observed: 38.1% of children improved in the group with persistence and 66.7% in the disease resolution group (P=.023). In addition, the correlations showed the level of improvement of snoring, as assessed by visual analogue scale. The mean was 5 points lower in the persistent group and 6.1 lower in the disease resolution group (P=.047).

CONCLUSION

Despite the limitations in the correlation between clinical data and polysomnography, especially in preoperative results, polysomnography remains the gold standard diagnostic tool. Efforts should be made to obtain objective parameters that provide higher levels of correlation.