Quality of life following surgery for sleep disordered breathing: subtotal reduction adenotonsillectomy versus adenotonsillectomy in Australian children

Adenotonsillectomy for Obstructive Sleep Apnea in Children

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.

Quality-of-life but not behavior improves 48-months post-adenotonsillectomy in children with SDB

BACKGROUND

Long term follow-up studies (>12 mths) of changes in behavior and quality-of-life (QoL) in children with sleep disordered breathing (SDB) post-adenotonsillectomy are limited and there is a lack of consensus in the reported findings. The aim of this study was to evaluate children's sleep, QoL and behavior at baseline and 6 mths and 48 mths post-adenotonsillectomy for clinically diagnosed SDB.

METHODS

This prospective longitudinal study of children aged 3-12 y recruited from a Children's Hospital otolaryngology clinic compared polysomnographic parameters, behavior (Child Behavior Checklist; CBCL) and QoL (OSA-18) at baseline, 6mths and 48mths post-adenotonsillectomy and compared these parameters to healthy non-snoring controls recruited from the general community at the same time points.

RESULTS

Sixty-four children completed sleep, behavior and QoL assessments (SDB = 20M/9F, Controls = 18M/17F) at all three time points. Sleep and ventilatory parameters significantly improved in children with SDB with minimal residual obstruction evident at 48 mths post-adenotonsillectomy. Compared to baseline, OSA-18 scores significantly improved post-adenotonsillectomy in children with SDB and were equivalent to the scores of controls at 6 mths and 48 mths post-AT. No significant improvement was observed in behavior in children with SDB post-adenotonsillectomy over the same time period.

CONCLUSION

Baseline deficits in sleep and QoL in children with SDB were normalized at 6 mths post-adenotonsillectomy and gains were maintained at 48 mths post-adenotonsillectomy. Children with SDB did not show significant gains in behavior either at 6 mths or 48 mths post-adenotonsillectomy.

Adenotonsillectomy for paediatric sleep disordered breathing in Australia and New Zealand

AIMS

To review the contributions of Australian and New Zealand research on adenotonsillectomy for the treatment of symptoms of obstructed breathing during sleep (sleep disordered breathing, SDB) in children.

METHODS

A search of the scientific literature was conducted using the MEDLINE (Ovid), PubMed and Scopus databases in August 2020. The following search string was used: (tonsillectomy OR adenoidectomy OR adenotonsillectomy) AND (paediatric OR child) AND (Australia OR New Zealand). A focused internet search was additionally conducted on Google to identify grey literature.

RESULTS

Researchers from Australia and New Zealand have made important contributions to the understanding and improvement of adenotonsillectomy (AT), including its epidemiology, cost, surgical techniques and peri-operative safety. Rates of AT have fluctuated over the years, becoming the most common paediatric surgery today, with SDB becoming the most common indication. Research in Australia and New Zealand has also focussed on the impact of AT on quality of life, and behaviour, neurocognition and cardiovascular sequelae.

CONCLUSIONS

Australian and New Zealand researchers have played a significant role in understanding the epidemiology and improving the safety of AT. There are promising directions in research still to come, including better understanding of the reasons for geographical variation in surgery rates, developing more efficient pre-operative risk assessment tools and alternative treatment options for mild OSA.

Consequences of paediatric sleep disordered breathing: contributions from Australian and New Zealand investigators

AIMS

To highlight the contributions of Australian and New Zealand researchers to the identification of the consequences of paediatric sleep disordered breathing (SDB).

METHODS

A search was conducted in PubMed using the terms "sleep disordered breathing" "child" and "Australia or New Zealand". All abstracts were reviewed and those which focused on the consequences of SDB have been included.

RESULTS

Australasian research into the consequences of SDB has grown exponentially over the last 35 years. SDB has significant adverse consequences for quality of life, behaviour, neurocognition and the cardiovascular system and the Australasian research studies investigating these are summarised.

CONCLUSIONS

Australian and New Zealand researchers have played a significant role in understanding the consequences of paediatric SDB and the mechanisms which underpin these. The research conducted "Downunder" has led the world in this field of research and will continue to provide evidence to improve the lives of children not only in Australasia but around the world.

Exploring the Factor Structure of the Glasgow Children's Benefit Inventory: New Recommendations for Reporting Results

OBJECTIVE

Patient-reported outcomes can be useful for reporting benefit from non-life-saving interventions, but often they report a single overall score, which means that much information on the specific areas of benefit is lost. Our aim was to perform a new factor analysis on the Glasgow Children's Benefit Inventory (GCBI) to create subscales reflecting domains of benefit. Further aims were to assess the internal consistency of the GCBI, and to develop guidelines for reporting both a total score and sub-scales in future studies.

METHODS

We collected 4 existing datasets of GCBI data from children who have undergone tonsillectomy, ventilation tube insertion, pinnaplasty, and submucous diathermy to the inferior turbinates. We performed exploratory factor analysis with principal axis factoring with varimax rotation, we sought redundancy in question items, and we measured internal consistency.

RESULTS

Using the combined dataset of 772 cases, we found 4 factors which accounted for 64% of the variance and which we have labeled "Psycho-social," "Physical health," "Behavior," and "Vitality." Subscale results varied in predictable ways depending on the nature of the intervention. Cronbach's alpha was 0.928. Item-total correlations were high, and no item could be deleted to improve alpha. Floor effects were apparent for various questions but were not consistent between different interventions.

CONCLUSIONS

The GCBI contains a range of questions which each add value in different clinical interventions. We can now make recommendations for reporting the results of the GCBI and its 4 new subscales.

Prospektive Erfassung der postinterventionellen Lebensqualität nach Adenotomie und Adenotonsillotomie bei Kindern

Hintergrund

Die Bewertung der Effektivität der Adenotomie (AT) und Adenotonsillotomie (ATT) bei symptomatischer adenotonsillärer Hyperplasie orientiert sich in Studien oft nur am Ausmaß der postoperativen Symptomreduktion. Daher sollte erstmals im Rahmen dieser Studie erfasst werden, ob die AT und ATT zu einer postoperativen Verbesserung der kindlichen Lebensqualität (LQ) mittels dem Fragebogen „Glasgow Children’s Benefit Inventory“ (GCBI) und einer visuellen Analogskala (VAS) zur LQ führt.

Material und Methoden

Es wurden n = 111 Kinder prospektiv rekrutiert (3 bis 6 Jahre, ♂ 65 % ♀ 35 %, Æ Alter 4,2 Jahre, AT (66 %), ATT (34 %), Follow-up 3,5 Monate). Die kindliche LQ wurde mittels GCBI (24 Items) und einer VAS zur LQ (0 bis 10 Punkte) erfasst.

Ergebnisse

Bei 107 Kindern (96,4 %) ergab sich eine postoperative Verbesserung der LQ anhand der GCBI-Score-Werte. Es ergab sich ein mittlerer Score-Wert von +32,7 ± 22,14, Konfidenzintervall (KI) [+28,5–+36,9] mit maximal +97,9 und minimal −25,0 Punkten. In der Gruppe ATT wurde mit +39,4 ± 25,18 ein signifikant höherer mittlerer Score-Wert als in der Gruppe AT +29,3 ± 19,67 erreicht (p = 0,024). Bei 91 (82,0 %) der Kinder gaben die Eltern postoperativ einen höheren Punktewert in der VAS an, bei 16 (14,4 %) bemerkten die Eltern keine Änderung, nur bei 4 (3,6 %) verschlechterte sich die LQ.

Diskussion

Schon die reine Rachenmandelhyperplasie beeinflusst die allgemeine LQ relevant. Die Verbesserung der LQ in GCBI und VAS durch die Operation belegt den klaren Benefit. Bei zusätzlicher Hyperplasie der Gaumenmandeln verbessert eine zusätzliche Tonsillotomie die LQ noch deutlicher. Adenotomie und Adenotonsillotomie sind daher bei differenzierter Indikationsstellung effektive Operationen, um neben der reinen Symptomreduktion auch eine signifikante Verbesserung der kindlichen LQ zu erzielen.

Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing

BACKGROUND

Recent evidence has challenged the practice of tonsillectomy in children with sleep-disordered breathing. Tonsillotomy (subtotal/partial/intracapsular tonsillectomy) has been proposed as an alternative with equivalent effectiveness and decreased post-operative morbidity, thus improving cost-effectiveness.

OBJECTIVE

To systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillotomy and tonsillectomy in paediatric (<16yo) patients with sleep-disordered breathing.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, and CENTRAL (1984-July 2014) was conducted. Papers in English directly comparing post-operative outcomes in tonsillectomy and tonsillotomy in children undergoing surgery for sleep-disordered breathing were included.

REVIEW METHODS

Two authors independently assessed abstracts for relevance, with disagreements resolved by a third author. Selected studies were independently assessed regarding inclusion and exclusion criteria.

RESULTS

Thirty-two studies satisfied inclusion and exclusion criteria (19 randomised, 13 non-randomised). Patient satisfaction, quality-of-life, and polysomnographic improvement post-surgery did not vary between tonsillotomy and tonsillectomy. Tonsillotomy reduced the odds of a secondary haemorrhage by 79% (OR 0.21, 95% CI 0.17-0.27, p < 0.01), decreased post-operative pain and reduced return to normal oral intake by 2.8 days (95% CI 1.08-4.52, p < 0.01). The odds of readmission were decreased by 62% (OR 0.38, 95% CI 0.23-0.60, p < 0.01). Tonsillotomy had a slightly higher rate of symptom recurrence (4.51%) than tonsillectomy (2.55%), the long-term impact of which was unclear.

CONCLUSION

Current evidence supports tonsillotomy in children with obstructive surgical indications. It is likely to reduce post-operative haemorrhage, pain, and facilitate a faster return to normal diet and activity. Healthcare burden is decreased due to fewer post-operative complications and reduced need for medical re-contact. More research is necessary to assess the risk of recurrence, and further classification of secondary haemorrhage severity is required to fully clarify the clinical benefit of tonsillotomy.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Tonsillectomy versus tonsillotomy for sleep-disordered breathing in children: a meta analysis

Objectives

Tonsillotomy has gained popular acceptance as an alternative to the traditional tonsillectomy in the management of sleep-disordered breathing in children. Many studies have evaluated the outcomes of the two techniques, but uncertainty remains with regard to the efficacy and complications of tonsillotomy versus a traditional tonsillectomy. This study was designed to investigate the efficacy and complications of tonsillotomy versus tonsillectomy, in terms of the short- and long-term results.

Methods

We collected data from electronic databases including MEDLINE, EMBASE, and the Cochrane Library. The following inclusion criteria were applied: English language, children, and prospective studies that directly compared tonsillotomy and tonsillectomy in the management of sleep disordered breathing. Subgroup analysis was then performed.

Results

In total, 10 eligible studies with 1029 participants were included. Tonsillotomy was shown to be advantageous over tonsillectomy in short-term measures, such as a lower hemorrhage rate, shorter operation time, and faster pain relief. In long-term follow-up, there was no significant difference in resolution of upper-airway obstructive symptoms, the quality of life, or postoperative immune function between the tonsillotomy and tonsillectomy groups. The risk ratio of SDB recurrence was 3.33 (95% confidence interval = 1.62 6.82, P = 0.001), favoring tonsillectomy at an average follow-up of 31 months.

Conclusions

Tonsillotomy may be advantageous over tonsillectomy in the short term measures and there are no significant difference of resolving obstructive symptoms, quality of life and postoperative immune function. For the long run, the dominance of tonsillotomy may be less than tonsillectomy with regard to the rate of sleep-disordered breathing recurrence.

Role of subtotal tonsillectomy (‘tonsillotomy’) in children with sleep disordered breathing

Introduction:

Sleep disordered breathing in children causes disturbance in behaviour and also in cardiorespiratory and neurocognitive function. Subtotal tonsillectomy (‘tonsillotomy’) has been performed to treat sleep disordered breathing, with outcomes comparable to established therapies such as total tonsillectomy or adenoidectomy. This review critically assesses the role of subtotal tonsillectomy in a paediatric setting.

Method:

The Medline database (1966 to October 2012) was electronically searched using key terms including subtotal or intracapsular tonsillectomy, tonsillotomy, tonsillectomy, paediatrics, and sleep disordered breathing.

Results:

Eighteen papers were identified and reviewed. Subtotal tonsillectomy would appear to have an efficacy equal to that of total tonsillectomy for the treatment of sleep disordered breathing, and has significant benefits in reducing post-operative pain and analgesia use. Subtotal tonsillectomy patients appear to have less frequent post-operative haemorrhage compared with total tonsillectomy patients.

Conclusion:

In children, subtotal tonsillectomy is associated with fewer post-operative complications whilst having a comparable effect in improving sleep disordered breathing, compared with total tonsillectomy.