Complications of adenotonsillectomy in children with OSAS younger than 2 years of age

Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

This meta-analysis aimed to assess the effectiveness and safety of (adeno)tonsillectomy (AT) for uncomplicated pediatric obstructive sleep apnea (OSA) across different age groups. Four electronic databases were searched until April 2022, and 93 studies (9087 participants) were selected, including before-after studies, cohort studies, and randomized controlled trials. It has been suggested that age, disease severity, and length of follow-up are associated with surgical effects. Compared with older children (>7 years), patients receiving AT surgery before the age of 7 exhibited a significantly greater release of disease severity, as well as a greater decrease in hypoxemic burden, improvement in sleep quality, and better cardiovascular function. Cognitive/behavioral performance also improved after AT, although it was more related to the length of follow-up than the age at surgery. Notably, the surgical complication rate was considerably higher in patients younger than 3 years old. Overall, we suggest that the age of 3-7 years might be optimal for AT in polysomnography-diagnosed uncomplicated OSA to maximize potential benefits for both disease and comorbidities and balance the risks of surgery.

Hot nasal packing with hot saline irrigation for hemostasis after adenoidectomy: A prospective randomized controlled study

OBJECTIVE

This study aimed to investigate the efficacy of hot posterior nasal packing and hot saline irrigation in bleeding control after adenoidectomy.

METHODS

A total of 130 patients scheduled for adenoidectomy were included in the study, and randomized into two groups at the beginning of the surgical operation. After adenoidectomy, saline impregnated tampon, and saline irrigation at room temperature (22 °C) was applied to the patients in one group while 50 °C saline impregnated tampon and saline irrigation at the same temperature were applied to the patients in the other group. We recorded hemostasis for up to 3 min after tamponade for bleeding control, and the amount of bleeding into the nasopharynx.

RESULTS

The age of the patients ranged from 1.5 to 13 years (mean ± SD: 6.07 ± 3.08 years, and 5.33 ± 2.55 years, 22 °C and 50 °C saline irrigation groups, respectively). There were 37 males and 28 females in the 22 °C saline group, while 34 males and 31 females in the 50 °C saline group. When comparing the two groups, there was no statistically significant difference in terms of duration of hemostasis (p = 0.64). However, bleeding scores at 2 nd min after the tamponade were significantly lower in the 50 °C saline group (p = 0.007). The amount of bleeding in the 50 °C saline group was also significantly lower than the 22 °C saline group (p = 0.015).

CONCLUSION

In this study, application of 50 °C saline impregnated tampon, and hot saline irrigation was found to be more effective in the control of bleeding after adenoidectomy by reducing the amount of bleeding compared to 22 °C saline impregnated tampon application and saline irrigation at 22 °C. However, hot nasal packing and hot saline irrigation did not affect duration of hemostasis and cauterization.

ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms (e.g. snoring) and/or conditions predisposing to SDB (e.g. mandibular hypoplasia) as well as children with SDB and complex conditions (e.g. Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions (e.g. supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy

OBJECTIVE

Systematically review the published literature comparing the presence of clinical features (age, BMI, co-morbidities, etc.) versus polysomnogram (PSG) results in the prediction of major post-operative respiratory complications following pediatric adenotonsillectomy (T/A) for the treatment of Obstructive Sleep Apnea Syndrome (OSAS).

METHODS

A systematic review of the PUBMED and EMBASE databases was performed to identify studies containing both clinical and PSG data predicting major post-operative respiratory complications following T/A. Inclusion criteria included English language and extractable data. Major respiratory complications were defined as events that required significant intervention (intubation, CPAP,etc.) and/or altered patient disposition. Random effect modeling was performed and study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Twenty-two studies met the inclusion criteria with a median sample size of 157 (range 26-1735) and published between 1992 and 2015. The most common study design was a case series. Most studies included multiple patients at high risk for respiratory complications (Syndromic, obese, etc.). The summary estimate of the major respiratory complication rate following T/A was only 5.8% (95% CI = 4.2-7.4%, p < 0.001, I² = 99%). For studies with extractable data, 102 of 112 patients (91.1%) with a post-operative respiratory complication had a clearly identifiable clinical risk factor, the remainder (8.9%) had only moderate or severe OSAS on PSG and no other predictor.

CONCLUSION

The major respiratory complication rate following pediatric T/A for OSAS is low even amongst series of high risk patients. The majority of the published literature report that readily identified clinical factors predict the large majority of post-operative respiratory complications following T/A.

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.

Pediatric obstructive sleep apnea syndrome

Pediatric obstructive sleep apnea syndrome (OSAS) is a common health problem diagnosed and managed by various medical specialists, including family practice physicians, pediatricians, pulmonologists, and general and pediatric otolaryngologists. If left untreated, the sequelae can be severe. Over the last decade, significant advancements have been made in the evidence-based management of pediatric OSAS. This article focuses on the current understanding of this disease, its management, and related clinical practice guidelines.

[Surgical treatment of sleep-related breathing disorders in children]

The surgical treatment of sleep-related breathing disorders in children depends on the cause of the upper airway obstruction, which can be located in the nasal fossae, pharynx (the most frequent adenotonsillar hyperplasia), or larynx (laryngomalacia, cysts…), or can be multilevel, as in syndromic diseases. Adenotonsillectomy is the most frequently performed and effective (70-80%) procedure. The aim of this technique is to normalize nocturnal respiratory parameters and daytime symptoms, as well as to revert, or at least to halt, cardiovascular complications, neurocognitive disturbances, growth delay and enuresis, which can develop if treatment is not provided or is delayed. However, despite its effectiveness, adenotonsillectomy more frequently leads to complications in children with sleep apnea-hypopnea syndrome (SAHS) than in those undergoing this procedure for other reasons. Moreover, 20-30% of children with SAHS who undergo adenotonsillectomy will show residual SAHS, and this percentage can increase to 70% in patients with severe SAHS, Down syndrome, craniofacial anomalies, neuromuscular disturbances, and morbid obesity. Consequently, both clinical and polysomnographic follow-up are recommended after adenotonsillectomy, especially in the latter risk group. Finally, other obstructive disorders of the upper airway must also be treated, although less frequently due to their lower incidence. These disorders include choanal atresia or stenosis, laryngomalacia, and hypoplasia of the midface or mandible. Tracheotomy will sometimes be required.

Day case tonsillectomy for the treatment of obstructive sleep apnoea syndrome in children: Alder Hey experience

BACKGROUND

The aim of this study was to assess the safety of paediatric adeno-tonsillectomy for obstructive sleep apnoea syndrome (OSAS) performed as a day case procedure.

METHODOLOGY

Postoperative airway related complications were prospectively evaluated in children undergoing adeno-tonsillectomy for OSAS over a 12-month period in a tertiary care centre. All data was analysed and descriptive statistics performed.

RESULTS

The overall incidence of postoperative airway related complications were 21 (10.4%) in 202 consecutively operated children. Eleven were in children with other medical co-morbidities (n=37) of which 8 occurred after 6h. Amongst those without any medical illnesses (n=165), two (1.2%) developed OSAS related complication after 6h of surgery only one of which needed medical/nursing intervention. The incidence of postoperative desaturations after 6h was 21.6% in those with co-morbidities.

CONCLUSION

It is safe to perform day case adeno-tonsillectomy for OSAS in children without any medical co-morbidities while those with other medical illnesses should be planned as in-patient procedures.

Surgical management of obstructive sleep apnea in infants and young toddlers

Objective: Review surgical management of obstructive sleep apnea (OSA) in infants and young toddlers compared with a medically treated group.

Study Design: Case series with chart review of children younger than 24 months treated at a tertiary pediatric hospital between 2000 and 2005.

Subjects and Methods: Surgical treatment included adenotonsillectomy, adenoidectomy, and tonsillectomy. Polysomnography results, comorbidities, and major complications were recorded. The change in apnea-hypopnea index (AHI) before and after treatment was analyzed. Logistic regression analysis reviewed effects of comorbidities and OSA severity on complications.

Results: A total of 73 children met inclusion criteria. The surgical treatment group (AHI) improved posttreatment: mean AHI change was 9.6 (95% CI, 5.8-13.4). The medical treatment group did not improve posttreatment: mean AHI change was −3.0 (95% CI, −15.1 to 9.1). The difference in AHI change between surgical and medical groups was 12.56 (95% CI, 2.7-22.4). An independent t test found this difference to be statistically significant ( P = 0.01). Eleven (18%) patients suffered significant postoperative surgical complications; 55 surgical patients and 8 medical patients had comorbidities. There were no long-term morbidities or mortalities.

Conclusions: AHI in the surgically treated group significantly improved. The complication rate for a tertiary pediatric hospital population that included patients with multiple comorbidities was acceptable.

An analysis of factors influencing postanesthesia recovery after pediatric ambulatory tonsillectomy and adenoidectomy

BACKGROUND

Many factors contribute to prolonged length of stay (LOS) for pediatric patients in the postanesthesia care unit (PACU). We designed this prospective study to identify the pre- and postoperative factors that prolong LOS.

METHODS

We studied 166 children, aged 1-18 yr, who underwent tonsillectomy and adenoidectomy or tonsillectomy and adenoidectomy, and bilateral myringotomy with tube insertion under general anesthesia. The primary outcome measure was the time spent in the PACU until predetermined discharge criteria were met.

RESULTS

The number of episodes of postoperative nausea and vomiting, patient age, and number of oxygen desaturations contributed significantly (P < 0.05) to prolonged LOS. Each episode of postoperative nausea and vomiting (P < 0.05) or oxygen desaturation to <95% (P < 0.05) increased the patient's LOS by 0.5 h. History of upper respiratory tract infection, emergence agitation, and parental anxiety did not significantly predict increased LOS.

CONCLUSION

This investigation is the first composite view of LOS in pediatric patients. The significance of identifying patients at risk of prolonged LOS prior to anesthesia is of use not only in allocating PACU resource and staffing needs, but also for improving quality of care and ensuring a minimally traumatic anesthetic experience for our pediatric patients and their families.

Adenotonsillectomy for obstructive sleep apnea in children with Prader-Willi syndrome

The aim of our study was to evaluate the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea syndrome (OSA) in pediatric patients with Prader-Willi syndrome (PWS), and to describe the postoperative complications. Five patients (4 males; median age, 4.4 years; range, 1.6-14.2 years) were studied. All patients underwent an overnight cardiorespiratory sleep study. All patients had adenotonsillar hypertrophy (ATH), and two were also obese. The preoperative obstructive apnea/hypopnea index (AHI; median and range) was 12.2 (9.0-19.9) events/hr; the mean oxygen saturation was 95 (79-96)%; the nadir oxygen saturation was 71 (58-78)%; and the oxygen desaturation index (ODI) was 15.8 (11.4-35.9) events/hr. Preoperatively, patients were classified as having moderate to severe OSA. A second sleep study, performed 16 (3-43) months after adenotonsillectomy, showed a significant decrease in AHI (P = 0.009) and ODI (P = 0.009). Mean and nadir oxygen saturation did not differ significantly postsurgery (P = 0.188, P = 0.073, respectively). Four out of five children showed at least one postoperative complication. Difficult awakening from anesthesia, hemorrhages, and respiratory complications requiring reintubation and/or supplemental oxygen administration were observed. In conclusion, patients with PWS and OSA who underwent adenotonsillectomy showed a significant decrease in AHI and number of oxygen desaturations.

The effect of polysomnography on pediatric adenotonsillectomy postoperative management

OBJECTIVE

We retrospectively investigated the effect and predictability of preoperative polysomnography (PSG) on the postoperative course of younger pediatric patients undergoing adenotonsillectomy.

STUDY DESIGN AND SETTING

A retrospective chart review was performed for patients 3 years of age and younger who had undergone adenotonsillectomy between July 1997 and July 2002 at the Children's Hospital of Wisconsin.

RESULTS

Two hundred eighty-two patients were identified. Forty-three patients had preoperative PSG. No correlation between the severity of PSG results and postoperative course was identified.

CONCLUSIONS

The role of PSG in upper airway obstruction and OSA remains controversial. This study suggests that although the complication rate may be higher in this younger population, these complications do not appear to have a large impact on their length of stay.

SIGNIFICANCE

This study suggests that the 3-years-and-younger group, in the absence of other comorbidities, can safely undergo adenotonsillectomy without undergoing preoperative PSG. EBM raing: C.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a major public health problem in the US that afflicts at least 2% to 4% of middle-aged Americans and incurs an estimated annual cost of 3.4 billion dollars. At Stanford, we utilize a multispecialty team approach combining the expertise of sleep medicine specialists (adult and pediatric), maxillofacial and ear, nose, and throat surgeons, and orthodontists to determine the most appropriate therapy for complicated OSA patients. The major treatment modality for children with OSA is tonsillectomy and adenoidectomy with or without radiofrequency treatment of the nasal inferior turbinate. Children with craniofacial anomalies resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or more invasive maxillary/mandibular surgery. Continuous positive airway pressure (PAP) therapy is used in children with OSA who are not surgical candidates or have failed surgery. As a last resort, tracheotomy may be used in patients with persistent or severe OSA who do not respond to other measures. The cornerstone of treatment in adults utilizes PAP: continuous PAP, bilevel PAP, or auto PAP. Treatment of nasal obstruction, appropriate titration, attention to mask-fit issues, desensitization for claustrophobia, use of heated humidification for nasal dryness and nasal pain with continuous PAP, patient education, regular follow-up, use of compliance software (in selected individuals), and referral to support groups (AWAKE) are measures that can improve patient compliance. Adjunctive treatment modalities include lifestyle/behavioral/pharmacologic measures. Oral appliances can be used in patients with symptomatic mild sleep apnea or upper airway resistance syndrome. Patients who are unwilling or unable to tolerate continuous PAP or who have obvious upper airway obstruction may benefit from surgery. Surgical success depends on appropriate patient selection, the procedure performed, and the experience of the surgeon. Phase I surgeries have a success rate of 50% to 60%, whereas phase II surgeries have a success rate greater than 90%.