Evaluation of sleep-disordered breathing in children

Impact of Chronic Adenoid Hypertrophy on Quality of Life Index in Children and Role of Adenoidectomy

Objectives: To analyze the effects of chronic adenoid hypertrophy on quality of life (QOL) of children and caregivers and compare quality of life of child before and after adenoidectomy. Materials & Methods: Prospective, observational before and after questionnaire based assessment study at a pediatric otorhinolaryngology specialty center in a metropolitan quaternary care hospital. Children aged between 2 and 12 years undergoing adenoidectomy were included. Parents were asked to fill the Obstructive Sleep Apnea-18 (OSA-18) Quality of Life Index Questionnaire one day before surgery and after one month of surgery during their scheduled follow-up visit. The study was conducted over a period of 1 year and total of 40 children's assessment was done. Results were tabulated and analyzed. Results: The mean age of presentation was 6 years. Based on OSA-18 quality of life assessment scoring the total pre-operative mean score was 73.3 and post-operative was 40.5. There was significant change in OSA-18 total score and individual domain scores post-operatively indicating significant improvement in QOL post adenoidectomy. The domains most affected due to chronic adenoid hypertrophy were physical suffering, caregiver concerns and sleep disturbance (p value < 0.001).Conclusion: Chronic adenoid hypertrophy has major impact on quality of life of a child along with caregiver concern and they show significant improvement after adenoidectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04000-z.

Evaluation of sleeping parameters with peripheral arterial tonometry in childhood sleep apnea and snoring: a clinical feasibility study

PURPOSE

The influence of adenoidectomy ± tonsillotomy/tonsillectomy on objective sleep parameters in children with Obstructive Sleep Apnea (OSA) was determined with the help of ambulatory polygraphy (WatchPat300^®, Neucomed Ltd., Vienna, Austria). These results were compared with the findings of the OSA-18 questionnaire.

METHODS

27 children treated with adenoidectomy ± tonsillotomy/tonsillectomy at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, were consecutively included in this prospective clinical trial. Pre- and postoperative objective sleeping parameters were assessed with outpatient polygraphy (WatchPat300^®) and subjective symptoms with the OSA-18 questionnaire.

RESULTS

Most of the children presented with severe OSA (41%, 11/27). The mean preoperative AHI was 10.2 (± 7.4). Postoperatively it declined to 3.7 (± 1.8; p < 0.0001). Following surgery 19/24 (79%) children had a mild OSA and 8/24 (21%) a moderate OSA. None of the children suffered from severe OSA anymore after surgery. The postoperative AHI did not correlate with the age (p = 0.3), BMIp (p = 0.6) or extent of surgery (p = 0.9). The mean postoperative OSA-18 survey score was significantly lower than the preoperative one (70.7 ± 26.7 vs. 34.5 ± 10.5; p < 0.0001). The postoperative OSA-18 questionnaire showed a normal survey score below 60 in 23/24 (96%) of the children.

CONCLUSIONS

The WatchPat^® device might be a feasible way for objective assessment of pediatric OSA in children older than 3 years. Adenoidectomy ± tonsillotomy/tonsillectomy caused a significant decrease of the AHI in children with OSA. This effect was especially pronounced in children with severe OSA and none of the children had persistent severe OSA after surgery.

Using sleep heart rate variability to investigate the sleep quality in children with obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is associated with impaired sleep quality and autonomic dysfunction. Adenotonsillectomy significantly improves subjective and objective sleep quality in children with OSA. However, the postoperative changes in heart rate variability (HRV) indices (indicators of cardiac autonomic function) and their importance remain inconclusive in childhood OSA. This retrospective case series aimed to investigate the association of sleep HRV indices, total OSA-18 questionnaire score (a subjective indicator of sleep quality) and polysomnographic parameters (objective indicators of sleep quality), and effects of adenotonsillectomy on HRV indices, total OSA-18 questionnaire score and polysomnographic parameters in children with OSA.

Methods

Seventy-six children with OSA were included in baseline analysis, of whom 64 (84%) completed at least 3 months follow-up examinations after adenotonsillectomy and were included in outcome analysis. Associations between baseline variables, and relationships with treatment-related changes were examined.

Results

Multivariable linear regression models in the baseline analysis revealed independent relationships between tonsil size and obstructive apnea-hypopnea index (OAHI), adenoidal-nasopharyngeal ratio and very low frequency (VLF) power of HRV (an indicator of sympathetic activity), and normalized low frequency power (an indicator of sympathetic activity) and OAHI. The outcome analysis showed that adenotonsillectomy significantly improved standard deviation of all normal-to-normal intervals, and high frequency power, QoL (in terms of reduced total OSA-18 questionnaire score), OAHI and hypoxemia. Using a conceptual serial multiple mediation model, % change in OSA-18 questionnaire score and % change in VLF power serially mediated the relationships between change in tonsil size and % change in OAHI.

Conclusions

The improvement in OAHI after adenotonsillectomy was serially mediated by reductions in total OSA-18 questionnaire score and VLF power. These preliminary findings are novel and provide a direction for future research to investigate the effects of VLF power-guided interventions on childhood OSA.

Adenotonsillar Hypertrophy: The Relationship Between Obstruction Type and Attention in Children

We aimed to investigate the attention function, which is a parameter of cognitive functions, at different obstruction types (adenoid and tonsil hypertrophy, adenoid hypertrophy only, tonsillar hypertrophy only, and normal) of oral cavity and nasopharynx, and the relationship between obstruction level, type, and attention (N = 80). To evaluate attention function, Stroop test has been performed. Eighteen-item Quality of Life (OSA-18) and Brouillette Symptom Score questionnaires have been completed with each child's parents. Significant and positive relation has been found between Brouillette Symptom Score, OSA-18 score, and each 5 sections of Stroop test's points. It has been shown that children with adenotonsillar hypertrophy (ATH) are negatively affected in terms of obstructive symptoms and quality of life. At the situation of obstructive pathology, the Stroop test durations are affected negatively. Results are supporting that quality of life and attention parameter are affected negatively at children with ATH.

OSA 18 Questionnaire: Tool to Evaluate Quality of Life and Efficacy of Treatment Modalities in Pediatric Sleep Disordered Breathing Due to Adenotonsillar Hypertrophy

Aims to evaluate quality of life in paediatric SDB due to adenotonsillar hypertrophy and efficacy of treatment modalities (medical and surgical) by using OSA-18 questionnaire. Prospective study, conducted from April 2019 to June 2019, including 42 patients with clinical features suggestive of SDB due to adenotonsillar hypertrophy, in age group of 3-15 years. Nasopharyngoscopy was done to grade adenoid hypertrophy. OSA-18 QOL questionnaire was recorded in all patients and depending upon the severity of impact of QOL and grades of adenoid hypertrophy, patients were categorized into two groups. Group 1 received medical treatment and group 2 underwent adenotonsillectomy. Questionnaire was again recorded after 4 weeks. Pretreatment and post-treatment total mean and individual domain scores were compared. Paired t tests was used to evaluate results. Group 1 included 16 children with mild to moderate impact and received medical management. Pretreatment mean OSA-18 score of 70.31 was improved to 33.5. Group 2 enrolled 26 patients with severe impact, were subjected to adenotonsillectomy. Pretreatment and post-treatment mean score were 95.88 and 24.92 respectively. Both groups showed statistically significant improvement in all individual domains and total mean OSA-18 scores indicating improvement in QOL after treatment and efficacy of medical management for mild-moderate SDB and surgery for severe cases. OSA-18 questionnaire is self-administered and disease specific screening tool for early diagnosis and evaluation of QOL before and after treatment. It also helps to categorize patients for advocating appropriate treatment and to evaluate efficacy of treatment modalities.

The effect of iron deficiency on quality of life outcomes after surgery for obstructive sleep apnoea

AIM

This study aimed to assess the effect of iron deficiency on parent-reported changes in quality of life (QOL) among children receiving an adenotonsillectomy for paediatric obstructive sleep apnoea (OSA).

METHODS

This was a retrospective review study that recruited children under 16 years of age undergoing an adenotonsillectomy, adenoidectomy, or tonsillectomy for clinically diagnosed paediatric OSA between June 2020 and January 2021 inclusive, in Western Australia. The main outcome measures for this study were changes in QOL by age group and iron status, defined by an absolute change of more than 3 points on OSA-18 survey domains.

RESULTS

About 249 participants had iron studies performed on perioperative blood samples drawn at operation and completed both pre-operative and post-operative OSA-18 QOL questionnaires at initial consultation and 8-12 weeks post-surgery, respectively. 41.8% were iron deficient, 53.8% were borderline iron deficient and 4.4% had normal iron levels. Following surgery, a decrease was observed for all OSA-18 score domains in post-operation scores compared to pre-operation scores in both iron-deficient and borderline iron-deficient cohorts. 'Daytime Problems' in the <2 years group, within the iron-deficient cohort, was the only domain that found to be non-superior (i.e. 'not better') following surgery.

CONCLUSIONS

Following adenotonsillectomy, patients with paediatric OSA reported significant improvements in QOL regardless of their iron status. Those undergoing an adenotonsillectomy for paediatric OSA had a high prevalence of iron deficiency at operation, especially those under 6 years of age.

Evaluation of Upper Airway Stimulation for Adolescents With Down Syndrome and Obstructive Sleep Apnea

Importance

Patients with Down syndrome have a high incidence of persistent obstructive sleep apnea (OSA) and limited treatment options. Upper airway hypoglossal stimulation has been shown to be effective for adults with OSA but has not yet been evaluated for pediatric populations.

Objective

To evaluate the safety and effectiveness of upper airway stimulation for adolescent patients with Down syndrome and severe OSA.

Design, Setting, and Participants

This prospective single-group multicenter cohort study with 1-year follow-up was conducted between April 1, 2015, and July 31, 2021, among a referred sample of 42 consecutive adolescent patients with Down syndrome and persistent severe OSA after adenotonsillectomy.

Intervention

Upper airway stimulation.

Main Outcomes and Measures

The prespecified primary outcomes were safety and the change in apnea-hypopnea index (AHI) from baseline to 12 months postoperatively. Polysomnographic and quality of life outcomes were assessed at 1, 2, 6, and 12 months postoperatively.

Results

Among the 42 patients (28 male patients [66.7%]; mean [SD] age, 15.1 [3.0] years), there was a mean (SD) decrease in AHI of 12.9 (13.2) events/h (95% CI, -17.0 to -8.7 events/h). With the use of a therapy response definition of a 50% decrease in AHI, the 12-month response rate was 65.9% (27 of 41), and 73.2% of patients (30 of 41) had a 12-month AHI of less than 10 events/h. The most common complication was temporary tongue or oral discomfort, which occurred in 5 patients (11.9%). The reoperation rate was 4.8% (n = 2). The mean (SD) improvement in the OSA-18 total score was 34.8 (20.3) (95% CI, -42.1 to -27.5), and the mean (SD) improvement in the Epworth Sleepiness Scale score was 5.1 (6.9) (95% CI, -7.4 to -2.8). The mean (SD) duration of nightly therapy was 9.0 (1.8) hours, with 40 patients (95.2%) using the device at least 4 hours a night.

Conclusions and Relevance

Upper airway stimulation was able to be safely performed for 42 adolescents who had Down syndrome and persistent severe OSA after adenotonsillectomy with positive airway pressure intolerance. There was an acceptable adverse event profile with high rates of therapy response and quality of life improvement.

Trial Registration

ClinicalTrials.gov Identifier: NCT02344108.

Long-term stability of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea in children with Down syndrome

IMPORTANCE

Obstructive sleep apnea (OSA) occurs in 55-97% of people with Down syndrome (DS). Even after adenotonsillectomy, residual OSA often persists into adulthood due, in part, to tongue base collapse. Implantable hypoglossal nerve stimulators are being investigated in children and young adults with DS and persistent, moderate to severe OSA. However, the long-term necessity for such an intervention-especially as patients mature and voltage adjustment becomes warranted-has not been previously reported in the pediatric DS population.

OBJECTIVE

To assess the long-term need for implantable hypoglossal nerve stimulators and the necessity for voltage adjustment in children and young adults with Down syndrome.

DESIGN

This is a case series from an ongoing clinical trial assessing safety and efficacy of hypoglossal nerve stimulation among 42 children and young adults with DS and persistent OSA, despite adenotonsillectomy and trialed positive airway pressure (PAP) therapy. We focus here on the first 4 participants who have undergone implantation by age 13 and have completed at least 44 months of follow-up.

PARTICIPANTS

4 participants (2 male, 2 female; ages 10-13 years) with DS and persistent, severe OSA (AHI > 10 events/h) underwent hypoglossal nerve stimulator implantation and were followed for 44-58 months.

SETTING

Participants completed in-lab sleep studies at baseline (before implantation), 1 year postoperatively, and 44-58 months postoperatively. During their most recent follow-up, 2 participants completed split-night sleep studies in which assessment was done with the device both on and off.

INTERVENTIONS

Hypoglossal nerve stimulator implantation.

MAIN OUTCOMES AND MEASURES

Stability in titrated and untitrated OSA as measured by the apnea-hypopnea index (AHI); growth measures including BMI; and quality of life as measured by the OSA-18 questionnaire.

RESULTS

Compared to baseline, all 4 participants maintained reductions of at least 50% in AHI over the course of follow-up. At recent follow-up, two participants had persistent, moderate OSA despite stimulation therapy. The other two participants achieved 100% reductions in AHI with stimulation therapy; when they underwent split-night sleep studies, the severe OSA persisted with the device turned off. Improvement in OSA-18 quality of life scores was observed in three of the four participants.

CONCLUSION

and Relevance: Hypoglossal nerve stimulation continues to effectively control OSA in children with DS as they mature, while their underlying untitrated OSA appears to persist into adulthood.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT2344108.

Redefining Success by Focusing on Failures After Pediatric Hypoglossal Stimulation in Down Syndrome

OBJECTIVES/HYPOTHESIS

Patients with Down syndrome have a high incidence of obstructive sleep apnea (OSA) and limited treatment options. Hypoglossal stimulation has shown efficacy but has not yet been approved for pediatric populations. Our objective is to characterize the therapy response of adolescent patients with down syndrome and severe OSA who underwent hypoglossal stimulation.

STUDY DESIGN

Prospective longitudinal trial.

METHODS

We are conducting a multicenter single-arm trial of hypoglossal stimulation for adolescent patients with Down syndrome and severe OSA. Interim analysis was performed to compare objective sleep and quality of life outcomes at 12 months postoperatively for the first 20 patients.

RESULTS

The mean age was 15.5 and baseline AHI 24.2. Of the 20 patients, two patients (10.0%) had an AHI under 1.5 at 12 months; nine patients of 20 (45.0%) under five; and 15 patients of 20 (75.0%) under 10. The mean decrease in AHI was 15.1 (P < .001). Patients with postoperative AHI over five had an average baseline OSA-18 survey score of 3.5 with an average improvement of 1.7 (P = .002); in addition, six of these patients had a relative decrease of apneas compared to hypopneas and seven had an improvement in percentage of time with oxygen saturation below 90%.

CONCLUSIONS

Patients with persistently elevated AHI 12 months after hypoglossal implantation experienced improvement in polysomnographic and quality of life outcomes. These results suggest the need for a closer look at physiologic markers for success beyond reporting AHI as the gold standard.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1663-1669, 2021.

Long-term Impact of Adenotonsillectomy on the Quality of Life of Children with Sleep-disordered breathing

Introduction  Adenotonsillectomy is the first-line treatment for obstructive sleep apnea secondary to adenotonsillar hypertrophy in children. The physical benefits of this surgery are well known as well as its impact on the quality of life (QoL), mainly according to short-term evaluations. However, the long-term effects of this surgery are still unclear.

Objective  To evaluate the long-term impact of adenotonsillectomy on the QoL of children with sleep-disordered breathing (SDB).

Method  This was a prospective non-controlled study. Children between 3 and 13 years of age with symptoms of SDB for whom adenotonsillectomy had been indicated were included. Children with comorbities were excluded. Quality of life was evaluated using the obstructive sleep apnea questionnaire (OSA-18), which was completed prior to, 10 days, 6 months, 12 months and, at least, 18 months after the procedure. For statistical analysis, p -values lower than 0.05 were defined as statistically significant.

Results  A total of 31 patients were enrolled in the study. The average age was 5.2 years, and 16 patients were male. The OSA-18 scores improved after the procedure in all domains, and this result was maintained until the last evaluation, done 22 ± 3 months after the procedure. Improvement in each domain was not superior to achieved in other domains. No correlation was found between tonsil or adenoid size and OSA-18 scores.

Conclusion  This is the largest prospective study that evaluated the long-term effects of the surgery on the QoL of children with SDB using the OSA-18. Our results show adenotonsillectomy has a positive impact in children's QoL.

[Diagnostics and treatment of adenotonsillar hyperplasia in children]

Adenoidectomy, paracentesis, and tonsillar interventions are the most common operations in childhood. Hypertrophy of the lymphatic tissue of Waldeyer's ring can lead to individually distinct, acute, and chronic symptoms as well as anatomical and functional changes. When presented with affected children in otolaryngologic practice, the combination of parental interview, questionnaire-based screening for obstructive sleep apnea syndrome, and physical examination including ear microscopy, inspection of the oropharynx and, if necessary, the nasopharynx, has proven its worth. Audiometric diagnosis for detection of tympanic effusion should be mandatory. The treatment of choice is adenoidectomy, if necessary plus tonsillotomy and paracentesis with a tympanic tube insert. However, the indication remains controversial, as the effectiveness of the interventions seems to depend on the preoperative severity of symptoms. With a correct indication, effective symptom reduction, improvement in quality of life, and high parent satisfaction can be expected.

Quality of Life and Behavioural Assessment in Post-adenotonsillectomy Cases of Paediatric Age Group

Adenotonsillectomy is a widely practiced surgical intervention to manage obstructive sleep apnoea syndrome (OSAS) in the paediatric age group. We conducted a prospective, non randomised, interventional study among 40 patients in paediatric age group (2-18 years) suffering from adenotonsillar hypertrophy with an indication of adenotonsillectomy based on American Academy of Otolaryngology-Head and Neck Surgery criteria. Care givers completed the obstructive sleep apnoea 18 (OSA 18) quality of life (QoL) survey and Rutter Children's Behaviour Questionnaire (RCBQ) before adenotonsillectomy as well as 6 months after surgery. We found that mean score of OSA 18 and total RCBQ decreased significantly 6 months after surgery. The mean score of OSA 18 (4.12 ± 1.4) and total RCBQ score (20.5 ± 2) significantly reduced to 1.19 ± 0.12 and 7.4 ± 2.55 (p < 0.0001), respectively, after surgery. There was significant improvement in all the domains of OSA 18 score after intervention including sleep disturbance (mean score change 2.56, p < 0.0001), physical suffering (2.99, p < 0.0001), emotional distress (2.71, p < 0.0001), daytime problems (2.56, p < 0.0001), caregiver concerns (3.76, p < 0.0001). We also observed that QoL as well as behaviour was independent of age and gender of patients. This study demonstrates significant score changes across all questionnaire domains, comparing pre and post operative data indicating an improvement in their quality of life and behaviour. Hence, we advocate that adenotonsillectomy may be considered as an effective treatment in properly selected patients with OSAS.

Measures of Health-Related Quality of Life Outcomes in Pediatric Neurosurgery: Literature Review

BACKGROUND

Improving value in healthcare means optimizing outcomes and minimizing costs. The emerging pay-for-performance era requires understanding of the effect of healthcare services on health-related quality of life (HRQoL). Pediatric and surgical subspecialties have yet to fully integrate HRQoL measures into practice. The present study reviewed and characterized the HRQoL outcome measures across various pediatric neurosurgical diagnoses.

METHODS

A literature review was performed by searching PubMed and Google Scholar with search terms such as "health-related quality of life" and "pediatric neurosurgery" and then including the specific pathologies for which a HRQoL instrument was found (e.g., "health-related quality of life" plus "epilepsy"). Each measurement was evaluated by content and purpose, relative strengths and weaknesses, and validity.

RESULTS

We reviewed 68 reports. Epilepsy, brain tumor, cerebral palsy, spina bifida, hydrocephalus, and scoliosis were diagnoses found in reported studies that had used disease-specific HRQoL instruments. Information using general HRQoL instruments was also reported. Internal, test-retest, and/or interrater reliability varied across the instruments, as did face, content, concurrent, and/or construct validity. Few instruments were tested enough for robust reliability and validity. Significant variability was found in the usage of these instruments in clinical studies within pediatric neurosurgery.

CONCLUSIONS

The HRQoL instruments used in pediatric neurosurgery are currently without standardized guidelines and thus exhibit high variability in use. Clinicians should support the development and application of these methods to optimize these instruments, promote standardization of research, improve performance measures to reflect clinically modifiable and meaningful outcomes, and, ultimately, lead the national discussion in healthcare quality and patient-centered care.

Hypoglossal Nerve Stimulation in Adolescents With Down Syndrome and Obstructive Sleep Apnea

Importance

Obstructive sleep apnea (OSA) affects up to 60% of children with Down syndrome (DS) and may persist in half of patients after adenotonsillectomy. Children with DS who have persistent OSA often do not tolerate treatment with positive pressure airway support devices or tracheotomy for their residual moderate to severe OSA. The hypoglossal nerve stimulator is an implantable device that delivers an electrical impulse to anterior branches of the hypoglossal nerve in response to respiratory variation, resulting in tongue base protrusion that alleviates upper airway obstruction in adults.

Objective

To determine whether hypoglossal nerve stimulation is safe and effective in children with DS.

Design, Setting, and Participants

Case series of the first 6 adolescents with DS to undergo hypoglossal nerve stimulator implantation. Participants were 6 children and adolescents (12-18 years) with DS and severe OSA (apnea hypopnea index [AHI] > 10 events/h) despite prior adenotonsillectomy.

Intervention

Inspire hypoglossal nerve stimulator placement.

Main Outcomes and Measures

Patients were monitored for adverse events. Adherence to therapy was measured by hours of use recorded by the device. Efficacy was evaluated by comparing AHI and OSA-18, a validated quality-of-life instrument, scores at baseline and follow-up.

Results

In 6 patients (4 male, 2 female; aged 12-18 years), hypoglossal nerve stimulator therapy was well tolerated (mean use, 5.6-10.0 h/night) and effective, resulting in significant improvement in OSA. At 6- to 12-month follow-up, patients demonstrated a 56% to 85% reduction in AHI, with an overall AHI of less than 5 events/h in 4 children and less than 10 events/h in 2 children. Children also demonstrated a clinically significant improvement (mean [SD] overall change score, 1.5 [0.6]; range, 0.9-2.3) on the OSA-18, a validated quality-of-life instrument.

Conclusions and Relevance

Hypoglossal nerve stimulation was well tolerated and effective in the study population, representing a potential therapeutic option for patients with DS and refractory OSA after adenotonsillectomy who are unable to tolerate positive pressure airway devices.

Trial Registration

clinicaltrials.gov Identifier: NCT2344108.

Improvement in symptoms of obstructive sleep apnoea in children following tonsillectomy versus tonsillotomy: a systematic review and meta-analysis

BACKGROUND

Tonsillotomy (or intracapsular tonsillectomy) is a modern technique which is seen by some as potentially superior to traditional (extracapsular) tonsillectomy for the removal of tonsillar tissue to treat obstructive sleep apnoea in children. It has been suggested that peri-operative pain and haemorrhage and postoperative haemorrhage are reduced with the tonsillotomy technique. However, no systematic reviews have been carried out to assess its efficacy in treating obstructive sleep apnoea compared to tonsillectomy.

OBJECTIVE OF REVIEW

To assess whether subjective improvement in symptoms of obstructive sleep apnoea following tonsillotomy is comparable to that following tonsillectomy, measured using a standardised questionnaire, the Obstructive sleep apnoea-18 (OSA-18) tool.

TYPE OF REVIEW

Systematic review of the literature and meta-analysis.

SEARCH STRATEGY

PubMed (MEDLINE), followed by Ovid (MEDLINE), Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and the British Medical Journal were searched for articles published in English between 1995 and 2015 inclusive.

EVALUATION METHOD

Literature search, systematic review and meta-analysis. Studies examining improvement in mean OSA-18 score following tonsillotomy, improvement in mean OSA-18 score following tonsillectomy, and examining both were selected, examined and used for meta-analysis. Studies with and without concurrent adenoidectomy were included.

RESULTS

Four studies examining tonsillotomy and 16 studies examining tonsillectomy were included in the analysis. Using a random effects model, the pooled improvement in OSA-18 score for tonsillotomy was 2.46 (95% CI 1.92-2.99), and for tonsillectomy, it was 2.10 (95% CI 1.91-2.30). There was no significant difference between the methods.

CONCLUSION

That there is no significant difference in subjective outcome between tonsillotomy and tonsillectomy may support wider use of tonsillotomy over tonsillectomy for the treatment of obstructive sleep apnoea in children.

Use of the Pediatric Quality of Life Inventory to Assess the Health-Related Quality of Life in Children with Recurrent Respiratory Papillomatosis

Objectives:

The objective of this study was to use the Pediatric Quality of Life Inventory (PedsQL), a 23-question modular instrument designed to measure the health-related quality of life (HRQOL) in children and adolescents, to compare the HRQOL in children with recurrent respiratory papillomatosis (RRP) with the HRQOLs reported for healthy children and children with other chronic medical conditions.

Methods:

The PedsQL version 4.0 Generic Core Scales consist of 23 questions in 4 subscales (Physical, Emotional, Social, and School Functioning) for parent-proxy reporting on the HRQOL in children ages 2 to 4 years, parent reporting for children 5 to 18 years, and child self-reporting for ages 5 to 7 years (age-adjusted questions and rating scales) and 8 to 18 years. The questionnaires were administered in person or by telephone to 22 children with RRP and (or, for children 2 to 4 years of age) one parent recruited from a tertiary pediatric otolaryngology practice. The results were compared with validated norms for healthy children and scores for children whose parents reported a chronic medical condition.

Results:

Compared with healthy controls, the children 5 to 18 years of age with RRP self-reported a significantly (p < .05) worse HRQOL as measured by the PedsQL Total Score, Psychosocial Health score (a combination of Emotional, Social, and School Functioning Scores), and Social Functioning and School Functioning scores. Self-reported scores for the children 5 to 18 years of age with RRP compared with children with other chronic illnesses followed the same trend, and the difference approached statistical significance (p = .05) for the School Functioning Subscale scores. The parent-proxy report (for children 2 to 18 years of age) scores for children with RRP were significantly lower (p < .0001) on every scale and in total compared with scores for healthy children. Compared with scores of children with other chronic medical conditions, the parent-proxy report scores were significantly lower for psychosocial health (p = .005) and school functioning (p<.0001).

Conclusions:

Children with RRP report a lower quality of life than do those who are healthy, and a quality of life similar to that of those who have other chronic medical problems. The parent reports also reflect a lower quality of life for children affected by this disease, as compared with healthy children. The PedsQL demonstrated a statistically significant low HRQOL in children with RRP; however, the clinical implications of this finding appear trivial. A distinct, disease-specific survey for RRP, if developed, would have enhanced responsiveness and sensitivity to change (due to the natural course of the disease and/or surgical treatments).

The Effect of Tonsillectomy and Adenoidectomy on Inattention and Impulsivity as Measured by the Test of Variables of Attention (TOVA) in Children with Obstructive Sleep Apnea Syndrome

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores.

STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care children's hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated.

RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was −2.9 (± 3.1). The mean postoperative TOVA score was −0.4 (±2.8). The improvement in the TOVA scores was significant ( P < 0.0001, t-test).

CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity.

SIGNIFICANCE: These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.

Cochrane Corner

The “Cochrane Corner” is a section in the journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review on tonsillectomy for obstructive sleep-disordered breathing (oSDB) in children, which finds moderate-quality evidence that surgery improves symptoms, behavior, and quality of life compared to nonsurgical management. The results apply to nonsyndromic children with SDB confirmed by polysomnography and must be balanced against a favorable natural history in many cases.

The efficacy of the OSA-18 as a waiting list triage tool for OSA in children

PURPOSE

Sleep disordered breathing (SDB) is common in children, resulting in extensive waiting lists for specialist clinics. There is an urgent need for a valid method of triaging patients and the OSA-18, a disease-specific tool, is an attractive candidate for this role. We aimed to examine the OSA-18 as a measurement tool in detail and to determine whether the score or aspects of it could be used as a screening tool for SDB in children.

METHODS

Retrospective analysis of 582 children (6 months to 16.4 years)-216 underwent overnight PSG and 366 overnight oximetry. Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were conducted. Receiver operating characteristic curve analysis assessed the diagnostic accuracy of the factors for the presence of OSA. Rasch analysis was used to assess the structure of the items (1-18) and categories of response (Likert scale).

RESULTS

The CFA with a forced five-factor structure, revealed three factors with Eigenvalues >1, and explained 73.7 % of the variance. EFA resulted in a two-factor structure, explaining 60.3 % of the variance. Assessment of sensitivity and specificity showed a high false-positive rate, irrespective of the factor structure tested. Rasch analysis showed poor discrimination between adjacent categories on the Likert scale.

CONCLUSION

This study confirmed that the predictive value of the OSA-18 for SDB severity is weak. Some questions perform better than others statistically, and the seven categories of response introduce significant statistical noise, raising the possibility that modification of the OSA-18 may improve its performance in the prediction of OSA severity.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thickness alterations of retinal nerve fiber layer in children with sleep-disordered breathing due to adenotonsillar hypertrophy

OBJECTIVE

This study is designed to assess whether hypoxia which is caused by apnea and hypopnea episodes, has an effect on retinal nerve fiber layer (RNFL) thickness, using optical coherence tomography (OCT) in pediatric patients with Adenotonsillar hypertrophy (ATH).

METHODS

Fifty-seven children patient with AHT, and 31 healthy non-AHT children (between 6 and 12 ages) were enrolled in this study. Obstructive symptoms of the patients with ATH were assessed by using OSA-18 survey. The patients were divided into 2 groups as mild (>60 and <80) and severe (>80) OSAS patients, according to OSA-18 survey total scores. RNFL thickness, in the four quadrants (superior, nasal, inferior and temporal) patient's both eyes, was measured by optical coherence tomography. RNFL parameters of control and patient groups were compared. Correlation between OSA survey scores and RNFL thickness of the patient groups were examined.

RESULTS

A positive correlation was found between ages and RNLF thickness of all subjects enrolled in this study (r=+0.107, p<0.05). And also a poor correlation was found between OSA-18 survey scores and RNFL parameters in patient group (between -0.031 and +0.016 at right and left eyes, p>0.05). No statistically significant alteration in RNFL thickness was found between the patient and control groups (p>0.05).

CONCLUSION

Age range (6-12) of the patients with ATH in our study considers that possible OSAS time was not long enough to affect RNLF thickness. Remembering the risk of optic injury development in children with ATH (in a long term), tonsillectomy and/or adenoidectomy operations shouldn't be delayed.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Population-based analysis of tonsil surgery and postoperative hemorrhage

Although tonsil surgery is one of the most frequent otorhinolaryngological procedures, not many population-based regional or country-wide studies are published on the incidence of postoperative bleeding and its risk factors. 2,216 patients underwent tonsil surgery in 2012 in Thuringia, a federal state in Germany. Most frequent indications were recurrent tonsillitis (44 % of all cases), tonsillar abscess (27 %), and tonsillar hyperplasia (20 %). 29 % of the patients were <10 years of age. Most frequent methods of surgery were tonsillectomy (73 %) and tonsillotomy (19 %). 215 patients (10 %) had 221 events of a postoperative hemorrhage. Re-surgery for hemostasis was necessary in 137 patients (6 %). The interval to re-surgery was 4.4 ± 4.6 days. The re-surgery rate was 8, 0.2, and 15 % after tonsillectomy, tonsillotomy, and radical tonsillectomy, respectively. In cases of recurrent tonsillitis, male gender (p < 0.001), age >24.78 years (median; (p = 0.018), and waiving of perioperative antibiotics (p = 0.029) were independent factors associated with hemorrhage. In cases of tonsillar hyperplasia tonsillectomy instead of tonsillotomy, the only significant risk factor was postoperative hemorrhage (p = 0.005). The overall incidence of tonsillar surgery was 87.6/100,000. The highest incidence was seen for patients 3-4 years of age with 862.7/100,000. In children <10 years, the incidence was always higher for boys than for girls. Throughout all age groups, a reverse gender relation was only seen, if surgery was indicated for recurrent tonsillitis. We recommend establishing national guidelines for indication of tonsil surgery, especially of tonsillectomy, including recommendations for perioperative care to decrease variations in tonsil surgery rates and minimize postoperative complications.

Validation of the Greek OSD-6 quality of life questionnaire in children undergoing polysomnography

OBJECTIVE

OSD-6 is a disease specific questionnaire for pediatric obstructive sleep apnea (OSA). The aims of this study were to validate OSD-6 in Greek language and correlate OSD-6 with polysomnography results.

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

OSD-6 questionnaire was translated to Greek and back to English. A prospective study was conducted on children undergoing overnight polysomnography due to snoring and disrupted sleep. Test-retest evaluation was carried out. Internal consistency and test-retest reliability were evaluated. Validity was assessed by exploring correlations between OSD-6 scores and apnea-hypopnea index (AHI), and by comparing total scores of OSA and non-OSA groups. Responsiveness was assessed by comparing preoperative to postoperative total scores in OSA children who underwent adenotonsillectomy.

RESULTS

Test-retest evaluation of 91 subjects showed good internal consistency (Cronbach's alpha 0.860 for test and 0.873 for retest) and reliability (Pearson's correlation coefficients between test and retest scores: 0.751-0.546; p<0.01). Total and domains' OSD-6 scores and AHI were significantly correlated (Spearman's correlation coefficients: 0.277-0.630; p<0.01), while children with OSA had higher total OSD-6 score than those without OSA (median (interquartile range): 16 (11) vs. 10 (7), respectively; p<0.01), indicating good validity. Postoperative OSD-6 scores were significantly lower than preoperative (2.84 ± 3.21 vs. 15.42 ± 6.48, respectively; p<0.001), suggesting good responsiveness.

CONCLUSION

The Greek version of the OSD-6 questionnaire proved to be a valid instrument with satisfactory internal consistency, reliability, validity and responsiveness. Furthermore, in our study OSD-6 was significantly correlated to polysomnography results.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep related quality of life before and after adenotonsillar surgery in pediatric population

OBJECTIVE

To assess the quality of life in children with adenotonsillar problems before and after adenotonsillectomy in short term follow-up.

METHODS

Quasi-experimental study (before and after study) of children with adenotonsillar problems at Tehran University of Medical Sciences, Amir'Alam hospital. Eighty six pediatric patients aged 3 through 13 years (58 boys and 28 girls) who underwent adenotonsillectomy, for treatment of sleep disordered breathing or recurrent throat infection, were recruited. Parents completed OSA-18 quality of life survey and Brouillette score questionnaire before and one month after surgery.

RESULTS

Reliability of the Brouillette score and OSA-18 survey was established by evaluating the Cronbach α value. Cronbach α for Brouillette score was 0.70 and for OSA-18 survey it was 0.88. Preoperative values for the OSA-18 total and domain scores were high in children: mean±SD; 61.65±20.78. Preoperative values for the Brouillette score were: mean±SD; 0.41±2.34. The total OSA-18 survey score and the scores for all domains showed significant improvement after surgery: mean±SD; 28.01±9.09 (P<0.001). Post-operative Brouillette score had a significant improvement: mean±SD; -3.57±0.91 (P<0.001).

CONCLUSION

Considering the OSA-18 survey and Brouillete score results, surgical therapy with adenotonsillectomy is associated with marked improvement in quality of life in both obstructive and infective adenotonsillar disease.

Obstructive sleep apnea: strategies for minimizing liability and enhancing patient safety

OBJECTIVE

To characterize malpractice litigation regarding obstructive sleep apnea (OSA) and educate physicians on frequently cited factors.

STUDY DESIGN AND SETTING

Analysis of the Westlaw legal database.

METHODS

Jury verdict and settlement reports were examined for outcome, awards, patient demographic factors, defendant specialty, and alleged causes of malpractice.

RESULTS

Out of 54 identified cases, 33 (61.1%) cases were resolved in favor of defendants, 12 (22.2%) via settlement, and 9 (16.7%) through jury award. Median settlement and jury awards did not significantly differ ($750,000 vs $550,000, P > .50). Age and gender did not affect outcome. Otolaryngologists and anesthesiologists were the most frequently named defendants. Forty-seven cases (87.1%) stemmed from OSA patients who underwent procedures with resultant perioperative adverse events. Common alleged factors included death (48.1%), permanent deficits (42.6%), intraoperative complications (35.2%), requiring additional surgery (25.9%), anoxic brain injury (24.1%), inadequate informed consent (24.1%), inappropriate medication administration (22.2%), and inadequate monitoring (20.4%).

CONCLUSION

Litigation related to OSA is frequently associated with perioperative complications more than nonoperative issues such as a failure to diagnose this disorder. Nonetheless, OSA is considerably underdiagnosed, and special attention should be paid to at-risk patients, including close monitoring of their clinical status and the medications they receive. For patients with diagnosed or suspected OSA with planned operative intervention, whether for OSA or an unrelated issue, a comprehensive informed consent process detailing the factors outlined in this analysis is an effective strategy to increase communication and improve the physician-patient relationship, minimize liability, and ultimately improve patient safety.

Quality of life in children with sleep-disordered breathing

Children may present sleep-disordered breathing (SDB) and suffer with adverse effects upon their quality of life.

Objective

This study assessed the quality of life of children with SDB, compared subjects with obstructive sleep apnea syndrome (OSAS) and primary snoring (PS), and identified which areas in the OSA-18 questionnaire are more affected.

Methods

This is a historical cohort cross-sectional study carried out on a consecutive sample of children with history of snoring and adenotonsillar hyperplasia. The subject's quality of life was assessed based on the answers their caregivers gave in the OSA-18 questionnaire and on diagnostic polysomnography tests.

Results

A number of 59 children participated in this study with mean age of 6.7 ± 2.26 years. The mean score of the OSA-18 was 77.9 ± 13.22 and the area most affected were “caregiver concerns” (21.8 ± 4.25), “sleep disturbance” (18.8 ± 5.19), “physical suffering” (17.3 ± 5.0). The impact was low in 6 children (10.2%), moderate in 33 (55.9%) and high in 20 (33.9%). PS was found in 44 children (74.6%), OSAS in 15 (25.6%). OSAS had higher score on “physical suffering” area than PS (p = 0.04). The AI (r = 0.22; p = 0.08) and AHI (r = 0.14; p = 0.26) were not correlated with OSA-18.

Conclusion

Sleep disordered breathing in childhood cause impairment in quality of life and areas most affected the OSA-18 were: “caregiver concerns”, “sleep disturbance” and “physical suffering”. OSAS has the domain “physical suffering” more affected than primary snorers.

Postnatal depression mediates the relationship between infant and maternal sleep disruption and family dysfunction

BACKGROUND

Previous research has linked family sleep disruption and dysfunction in children; however, the mechanism is unknown.

AIMS

This study examined whether maternal sleep and postnatal depression (PND) mediate the relationship between infant sleep disruption and family dysfunction.

STUDY DESIGN AND PARTICIPANTS

Mothers of infants aged 12 months old (N=111; 48% male) completed infant and parent sleep surveys, the Edinburgh Postnatal Depression Scale and the Family Assessment Device.

RESULTS

Poor infant sleep was related to poor maternal sleep, which was associated with higher PND and higher level of family dysfunction.

CONCLUSIONS

Results are consistent with the proposition that identification of both infant and maternal sleep problems during infancy can be relevant to reduction of PND and improved family functioning.

Diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).

METHODS

The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS

A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

Modified Adenotonsillectomy to Improve Cure Rates for Pediatric Obstructive Sleep Apnea

Objective

To compare the efficacy of adenotonsillectomy (T&A) with and without pharyngoplasty (tonsillar pillar closure) in the treatment of pediatric obstructive sleep apnea-hypopnea syndrome (OSAHS).

Study Design

Randomized single-blind controlled study.

Setting

Tertiary care center.

Subjects and Methods

Sixty pediatric patients with a clinical diagnosis of OSAHS presenting between January 2009 and December 2010 were enrolled and randomized to undergo either standard T&A (n = 30) or T&A with pharyngoplasty (n = 30). Surgical cure was defined as apnea-hypopnea index (AHI) <5 plus OSA-18 health-related quality-of-life (HRQL) score <60. Other outcomes included postsurgical AHI and minimum oxygen saturation (SpO2) improvement, changes in OSA-18 scores at 1 month, and postsurgical days to resume normal diet and activity.

Results

Three patients from each group did not undergo surgery. Of the 54 patients treated, 8 from the pharyngoplasty group and 2 from the standard group were lost to follow-up. Intention-to-treat analysis revealed no difference in cure rate between groups (standard 60%, pharyngoplasty 56.6%, P = .793). Limiting analysis to those patients with complete data, a higher, but not significantly increased, cure rate with pharyngoplasty was noted (72% vs 89.5%, P = .155). Greater OSA-18 improvement ( P = .036) and greater (although nonsignificant) AHI improvement and earlier return to normal function were noted with pharyngoplasty.

Conclusion

The addition of pharyngoplasty to traditional adenotonsillectomy did not significantly improve OSAHS cure rates as measured by sleep testing and HRQL, although a nonsignificant increase in cure rate was observed in those who completed the study protocol. An unexpectedly high rate of patient dropout rendered the study statistically underpowered and therefore inconclusive.

Outcome of adenotonsillectomy for sleep and breathing difficulties in nigerian children with obstructive adenotonsillar enlargement

The aim of this study was to examine improvements or otherwise, in sleep disturbance and breathing difficulties after adenotonsillectomy (AT) for chronic upper airway obstruction in children. In a prospective clinical study and tertiary referral center setting, the study population included consecutive children aged 1.5 through 12 years who underwent AT for chronic upper airway obstruction due to adenotonsillar enlargement, without any history of previous AT. The validated "Symptomatology score" (SS) parameters were used to grade the symptoms before and after AT. The extent of improvement of the symptoms after surgery were estimated by a standardized response mean (SRM). The study included 59 children, 40 of whom were males (68%). Their ages ranged from 1.5 to 12 years with a mean of 3.3 years and 63% were <4 years. The results showed that tonsillar size was correlated significantly with a high preoperative SS (P ≤ 0.001). The mean preoperative SS for the study population was 7.2, whereas the mean postoperative SS was 1.7. This change was highly significant (P < 0.001). The symptom domain with the greatest change in mean score was snoring, which improved by 2 points with SRM of 2.2. The changes in total score and in the scores for each symptom domain were highly significant (P < 0.002). We concluded that adenotonsillectomy is associated with remarkable improvement in breathing difficulties and sleep disturbances in children with obstructive adenotonsillar hypertrophy regardless of the condition whether it is mild or severe.

Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections: open randomised controlled trial

OBJECTIVE

To assess the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections.

DESIGN

Open randomised controlled trial.

SETTING

11 general hospitals and two academic centres.

PARTICIPANTS

111 children aged 1-6 with recurrent upper respiratory tract infections selected for adenoidectomy.

INTERVENTION

A strategy of immediate adenoidectomy with or without myringotomy or a strategy of initial watchful waiting. Main outcome measure Primary outcome measure: number of upper respiratory tract infections per person year calculated from data obtained during the total follow-up (maximum 24 months).

SECONDARY OUTCOME MEASURES

days with upper respiratory tract infection per person year, middle ear complaints with fever in episodes and days, days with fever, prevalence of upper respiratory tract infections, and health related quality of life.

RESULTS

During the median follow-up of 24 months, there were 7.91 episodes of upper respiratory tract infections per person year in the adenoidectomy group and 7.84 in the watchful waiting group (difference in incidence rate 0.07, 95% confidence interval -0.70 to 0.85). No relevant differences were found for days of upper respiratory tract infections and middle ear complaints with fever in episodes and days, nor for health related quality of life. The prevalence of upper respiratory tract infections decreased over time in both groups. Children in the adenoidectomy group had significantly more days with fever than the children in the watchful waiting group. Two children had complications related to surgery.

CONCLUSION

In children selected for adenoidectomy for recurrent upper respiratory tract infections, a strategy of immediate surgery confers no clinical benefits over a strategy of initial watchful waiting. Trial registration Dutch Trial Register NTR968: ISRCTN03720485.

Effect of Adenotonsillectomy on Endothelin-1 and C-Reactive Protein Levels in Children with Sleep-Disordered Breathing

Objective. This study aimed to evaluate the influence of adenotonsillectomy on the plasma concentration of endothelin-1 (ET-1) and C-reactive protein (CRP) in children with sleep-disordered breathing (SDB). The relationship between quality of life and ET-1 levels was also evaluated.

Setting. Tertiary referral center.

Study Design. Before-and-after case series.

Methods. Fasting blood samples for ET-1 and high-sensitivity CRP were drawn preoperatively in all patients and at 3 to 4 months postoperatively. The Obstructive Sleep Apnea–18 (OSA-18) survey and Brouilette symptom score were completed by each child’s parents during the same time periods.

Results. The mean ET-1 level decreased from 3.51 ± 0.93 fmol/mL to 2.67 ± 0.69 fmol/mL postoperatively ( P < .01). OSA-18 survey scores and Brouilette symptom scores also decreased in the postoperative period ( P < .01). When comparing moderate and severe cases to mild cases according to Brouilette scores, ET-1 levels were significantly higher in moderate and severe cases ( P < .01). There was a significant correlation between ET-1 and the OSA-18 survey scale ( r = 0.442; P = .001). Although CRP levels decreased from 0.63 ± 1.19 mg/dL to 0.31 ± 0.23 mg/dL postoperatively, this was not statistically significant.

Conclusion. Adenotonsillectomy effectively lowered plasma ET-1 levels in children with SDB and thus may have reduced their related risk for cardiovascular disease. In addition, adenotonsillectomy improved quality of life in this group.

Role of intranasal topical steroid in pediatric sleep disordered breathing and influence of allergy, sinusitis, and obesity on treatment outcome

Objectives

To evaluate efficacy of short term intranasal corticosteroid (mometasone furoate) treatment in pediatric sleep-disordered breathing (SDB) patients.

Methods

A prospective, observational study was done. A total of 41 children (2-11 years old) were enrolled into this study. All patients received 4-weeks course of mometasone furoate 100 µg/day treatment. They were evaluated at pretreatment and immediately after treatment with obstructive sleep apnea (OSA)-18 quality of life survey and lateral neck X-ray. Also, the assessment of each patients included history, skin prick test or CAP test, and sinus radiography. We compared the OSA-18 survey score and adenoidal-nasopharyngeal (AN) ratio between before and after treatment.

Results

Total OSA-18 score and AN ratio decreased significantly after treatment regardless of allergy, sinusitis, and obesity (P=0.003, P=0.006). There was no complication after treatment of mometasone furoate.

Conclusion

Pediatric SDB patients with adenoid hypertrophy could be effectively treated with 4-weeks course of mometasone furoate. Allergy, obesity, and sinusitis did not affect on the result of treatment.

Development of pediatric sleep questionnaires as diagnostic or epidemiological tools: a brief review of dos and don'ts

Questionnaires are a useful and extensively used tool in clinical sleep medicine and in sleep research. The number of sleep questionnaires targeting the pediatric age range has tremendously increased in recent years, and with such explosion in the number of instruments, their heterogeneity has become all the more apparent. Here, we explore the theoretical and pragmatic processes required for instrument design and development, i.e., how any questionnaire, inventory, log, or diary should be created and evaluated, and also provide illustrative examples to further underline the potential pitfalls that are inherently embedded in every step of tool development.