Children with tonsillar obstruction: indications for and efficacy of tonsillectomy

The First-Line Approach in Children with Obstructive Sleep Apnea Syndrome (OSA)

Obstructive sleep apnea syndrome (OSA) is the main manifestation of sleep-disordered breathing in children. Untreated OSA can lead to a variety of complications and adverse consequences mainly due to intermittent hypoxemia. The pathogenesis of OSA is multifactorial. In children aged 2 years or older, adenoid and/or tonsil hypertrophy are the most common causes of upper airway lumen reduction; obesity becomes a major risk factor in older children and adolescents since the presence of fat in the pharyngeal soft tissue reduces the caliber of the lumen. Treatment includes surgical and non-surgical options. This narrative review summarizes the evidence available on the first-line approach in children with OSA, including clinical indications for medical therapy, its effectiveness, and possible adverse effects. Literature analysis showed that AT is the first-line treatment in most patients with adenotonsillar hypertrophy associated with OSA but medical therapy in children over 2 years old with mild OSA is a valid option. In mild OSA, a 1- to 6-month trial with intranasal steroids (INS) alone or in combination with montelukast with an appropriate follow-up can be considered. Further studies are needed to develop an algorithm that permits the selection of children with OSA who would benefit from alternatives to surgery, to define the optimal bridge therapy before surgery, to evaluate the long-term effects of INS +/- montelukast, and to compare the impact of standardized approaches for weight loss.

Impact of tonsillotomy versus tonsillectomy on health-related quality of life and healthcare costs in children with sleep-disordered breathing

Objective

This study aimed to explore health-related quality of life and use of healthcare services and ensuing costs before and after tonsillotomy in children with sleep-disordered breathing and to compare the results to an earlier cohort of children who had undergone tonsillectomy.

Method

Children undergoing tonsillotomy answered the 17-dimensional, standardised health-related quality of life instrument questionnaire and a questionnaire on use of healthcare services and sick leave before and after surgery. Costs of specialist care were obtained pre- and post-operatively. The data were compared with similar data collected previously from children with tonsillectomy.

Results

Tonsillotomy improved mean total health-related quality of life score significantly at 6 and 12 months. Healthcare costs and number of sick-leave days diminished significantly from 3 months pre-operatively to 12 months after surgery. Tonsillotomy had similar positive effects compared with tonsillectomy regarding health-related quality of life and healthcare costs.

Conclusion

Tonsillotomy improves health-related quality of life in children with sleep-disordered breathing and reduces healthcare service needs and sick leave similarly to tonsillectomy.

Correlation between Malocclusion and Allergic Rhinitis in Pediatric Patients: A Systematic Review

BACKGROUND

Oral breathing, nasal obstruction and airway space reduction are usually reported as associated to allergic rhinitis. They have been linked to altered facial patterns and dento-skeletal changes. However, no firm correlation based on the evidence has been established. This systematic review has been undertaken to evaluate the available evidence between malocclusion and allergic rhinitis in pediatric patients.

METHODS

The research refers to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines, databases (Medline, Cochrane Library, Pubmed, Embase and Google Scholar) were screened, the quality was evaluated through Quality Assessment of Diagnosfic Accuracy Studies (QUADAS-2).

RESULTS

The articles selected (6 out of initial 1782) were divided on the basis of the study design: two observational randomized study, three case-control study, one descriptive cross-sectional study, and one longitudinal study. A total of 2188 patients were considered. Different results were reported as related to allergic rhinitis ranging from a higher incidence of dental malocclusion, to an increase of palatal depth, and in posterior cross-bite about anterior open-bite and to longer faces and shorter maxillas.

CONCLUSIONS

Most of the studies selected found a rise in the prevalence of both malocclusion and allergic rhinitis in children. However, the level of bias is high, impaired by a poor design and no conclusive evidence can be drawn.

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.

Influence of adenotonsillar hypertrophy on /s/-articulation in children--effects of surgery

Tonsillar hypertrophy is common in young children and affects several aspects of the speech such as distortions of the dento-alveolar consonants. The study objective was to assess /s/-articulation, perceptually and acoustically, in children with tonsillar hypertrophy and compare effects of two types of surgery, total tonsillectomy and tonsillotomy. Sixty-seven children, aged 50-65 months, on the waiting list for surgery, were randomized to tonsillectomy or tonsillotomy. The speech material was collected preoperatively and 6 months postoperatively. Two groups of age-matched children were controls. /S/-articulation was affected acoustically with lower spectral peak locations and perceptually with less distinct /s/-production before surgery, in comparison to controls. After surgery /s/-articulation was normalized perceptually, but acoustic differences remained. No significant differences between surgical methods were found.

Phonological development in children with obstructive sleep-disordered breathing

Adeno-tonsillar hypertrophy with obstructive sleep disordered breathing (OSDB) is known to affect oral-motor function, behaviour, and academic performance. Adeno-tonsillectomy is the most frequently performed operation in children, with total tonsillectomy (TE) being more common than partial resection, 'tonsillotomy' (TT). In the present study 67 children, aged 50-65 months, with OSBD were randomized to TE or TT. The children's phonology was assessed pre-operatively and 6 months post-operatively. Two groups of children served as controls. Phonology was affected in 62.7% of OSBD children before surgery, compared to 34% in the control group (p < .001). Also, OSBD children had more severe phonological deficits than the controls (p < .001). Phonology improved 6 months equally after both surgeries. Despite improvement post-operatively, the gap to the controls increased. Other functional aspects, such as oral motor function, were normalized regardless of surgical method--TE or TT. The impact of OSBD should be considered as one contributing factor in phonological impairment.

Surgery for Pediatric Sleep Apnea

Sleep-related breathing disorders (SRBD) in children are caused by a diverse group of anatomic and physiologic pathologies. These disorders share a common clinical presentation as stertor or sonorous breathing, occasionally accompanied by apneic events of variable duration. Successful management depends on accurate identification of the site of obstruction and the severity of obstruction. Intervention, both surgical and nonsurgical, is tailored to the disorder. In children with SRBD, such intervention may alter behavior and cognition, improve sleep and feeding, or even save a life.

Adenotonsillectomy in obstructive sleep apnea syndrome. Proposal of a surgical decision-taking algorithm

OBJECTIVE

The incidence of snoring in the pediatric population is 10% and the incidence of OSAS is equal to 2-3%. Sometimes, primary snoring and OSAS overlap and only polysomnography can differentiate the two disorders but its use is complex, expensive and highly controversial. The purpose of this paper is to demonstrate the value of the clinical assessment associated with the patient's history in selecting children with OSAS and to validate the therapeutic algorithm, thereby employing polysomnography only for selected cases.

METHODS

A population of 118 patients was considered, selected by means of a questionnaire that indicated OSAS and a clinical evaluation that confirmed the diagnosis. The studied group underwent clinical assessment complete with fibreoptic survey as well as nocturnal pulse oxymetry, orthodontic and phoniatric evaluation. Regardless of the adenotonsillar size, all the selected children underwent adenotonsillectomy and were evaluated after 3 months with the help of a questionnaire, ORL examination and nocturnal pulse oxymetry.

RESULTS

In all the patients we witnessed the disappearance of apnea. A 80.5% of children benefited from the surgical procedure. A 12.7% continued to present minor symptoms. A 6.8% continued to snore in a discontinuous manner, but without apnea: these children were re-assessed after a further 6 months with nocturnal pulse oxymetry and no oxymetric alteration was demonstrated. There were no significant differences between the degree of upper airway obstruction and the surgical outcome.

CONCLUSION

The history and clinical exam are sensitive tools, even though relatively aspecific. Our results confirm the validity of the history and clinical exam as a screening method as well as the role of the surgical procedure that can re-establish the patency of the upper airways and to contrast the neuromuscular hypotonia as a result of the effect of the surgical scar. If it is true that primary snoring and OSAS are a continuum, our approach regarding surgery may be defined as a form of prevention regarding a pathology with potential complications. Polysomnography cannot be carried out routinely due to the lack of specialised centres and because of its excessive cost. It is an option to be used only in unsuccessful adenotonsillectomies and for those children who have complicated presentations from the outset.

The Correlation Among Obesity, Apnea-Hypopnea Index, and Tonsil Size in Children

BACKGROUND

The correlation between obesity and severity of obstructive sleep apnea (OSA) is well established in adults, but data are inconsistent in children. We hypothesized that there is a significant correlation between the degree of obesity and the severity of OSA in children.

METHODS

We retrospectively reviewed records of weight, height, history, and polysomnography of all 1- to 15- year-old children referred to our sleep laboratory. Children with known anomalies and repeated polysomnography were excluded from this study. Obesity was defined as body mass index z score (BMI Z score) > 1.96. The correlation between BMI Z score and apnea-hypopnea index (AHI) was assessed. Possible confounding factors, ie, age, gender, and tonsil size, were adjusted by multiple linear regression.

RESULTS

Four hundred eighty-two children were included in this study. Obese children had a significantly higher AHI (median, 1.5; interquartile range [IQR], 0.2 to 7.0) than the AHI of nonobese children (median, 0.7; IQR, 0.0 to 2.5). BMI Z score was significantly correlated with log-transformed AHI (Ln[AHI]) [r = 0.156, p = 0.003]. BMI Z score and tonsil size were still correlated with Ln(AHI) even after adjusted for other confounding factors (p = 0.001).

CONCLUSION

Degree of obesity as measured by BMI Z score and tonsil size are significantly related to severity of OSA as reflected by the AHI, although the correlation is mild.

Pediatric Tonsillotomy with Radiofrequency Technique: Long-Term Follow-Up

OBJECTIVES

Compare the effects of partial tonsil resection using a radiofrequency technique, tonsillotomy (TT), with total tonsillectomy (TE, blunt dissection) after 1 and 3 years. Compare frequency of relapse in snoring or infections and possible long-term changes in behavior among TT children with those in TE children.

METHOD

Ninety-two children (5-15 yr) randomized to TT (n = 49) or TE (n = 43) groups because of obstructive problems with or without recurrent tonsillitis. One year after surgery, general health, degree of obstruction, history of infections, and behavior were investigated using two questionnaires, the Qu1 and Child Behavior Checklist, as well as an ENT visit. After 3 years, two questionnaires, Qu2 and the Glasgow Children's Benefit Inventory, were answered by mail.

RESULTS

: After 1 year, both groups were in good health. The effect on snoring and total behavior was the same for both groups, and the rate of recurrence of infections was not higher in the TT group. After 3 years, two children in the TT group were tonsillectomized (4%, 2/49), one because of peritonsillitis and another because of increased snoring. Otherwise, no differences existed between the groups in general health, snoring, or number of infections.

CONCLUSION

Removing only the protruding parts of the tonsils has the same beneficial long-term effect on obstructive symptoms and recurrent throat infections as complete TE in the majority of cases. The need for re-operation is low; therefore, it appears inadvisable to follow the current common practice of routinely removing the whole tonsil given its higher morbidity and risk for serious complications.

Pediatric adenoidectomy: what is the effect of obstructive symptoms on the likelihood of future surgery?

OBJECTIVE

Determine if pediatric patients undergoing adenoidectomy for obstruction have an increased likelihood of undergoing eventual tonsillectomy and/or second adenoidectomy over extended follow-up.

METHODS

Retrospective cohort study within the ambulatory surgery component of a tertiary children's hospital. Exclusion criteria consisted of the presence of significant co-morbid conditions (obesity, craniofacial syndrome, cerebral palsy, etc.) and less than 1 year of post-adenoidectomy follow-up. The study population included 100 children (mean age=3.9 years, range 0.9-15 years) randomly selected from a financial billing database undergoing adenoidectomy either with pre-operative obstructive symptoms (OB n=52) or without pre-operative obstructive symptoms (NOB n=48) with a minimum of 1 year of retrospective follow-up. Electronic records were searched for subsequent surgery (tonsillectomy and/or revision adenoidectomy).

RESULTS

Overall, 29 of 100 children (29%) underwent subsequent surgery (tonsillectomy and/or revision adenoidectomy) over an average of 3.46 years (range 1.0-6.59 years) retrospective follow-up. Children in the OB group were three times more likely (age, sex adjusted odds ratio=3.03, 95% confidence interval =1.18-7.78 p=0.021) than children in the NOB group to require tonsillectomy or second adenoidectomy. Age less than 2 years at time of initial adenoidectomy also suggested an increased likelihood of subsequent surgery.

CONCLUSION

Children undergoing adenoidectomy with obstructive symptoms are more likely to require eventual tonsillectomy and/or second adenoidectomy than those undergoing adenoidectomy without obstruction. However, the low absolute likelihood of future surgery precludes a generalized recommendation for tonsillectomy in these children.

Relation of Isolated Tonsillar Hypertrophy with Body Mass Index

OBJECTIVE

The purpose of this study was to investigate the relationship between tonsillar hypertrophy and body mass index (BMI).

MATERIAL AND METHODS

This is a cross-sectional study which was conducted in three primary schools located in Duzce. A total of 1,282 children between 7 and 12 years of age were evaluated and the size of their tonsils was investigated with regard to height and weight. This study was performed in the course of school screening, and the correlation between estimated tonsil size and BMIs of the children was investigated.

RESULTS

Sixteen of 1,282 students were excluded from the study, leaving 1,266 children in the study. The mean (+/-SD) age of the children was 9.13 +/- 1.45 (range 7-12) years. The mean height of the 1,266 children was 129.07 +/- 9.95 (range 105-163) cm, the mean weight was 28.81 +/- 6.96 (range 15-68) kg, and the mean BMI was 17.09 +/- 2.33 (range 12.07-30.0) kg/m(2). There was no statistically significant effect of tonsil size on BMI. We could not find a significant relation of isolated tonsillar hypertrophy with BMI.

CONCLUSIONS

No relation could be found between tonsillar hypertrophy and BMI.

Breathing mode influence in craniofacial development

AIM

The aim of this study was to evaluate the differences in facial proportions of nose and mouth breathing children using cephalometric analysis.

STUDY DESIGN

Transversal cohort.

MATERIAL AND METHOD

Sixty cephalometric radiographs from pediatric patients aged 6 to 10 years were used. After otorhinolaryngological evaluation, patients were divided into two groups: Group I, with mouth breathing children and group II, with nose breathers. Standard lateral cephalometric radiographs were obtained to evaluate facial proportions using the following measures: SN.GoGn, ArGo.GoMe, N-Me, N-ANS, ANS-Me and S-Go; and the following indexes: PFH-AFH ratio: S-Go/N-Me; LFH-AFH ratio: ANS-Me/N-Me and UFH-LFH ratio: N-ANS/ANS-Me.

RESULTS

It was observed that the measurements for the inclination of the mandibular plane (SN.GoGn) in mouth breathing children were statistically higher than those in nasal breathing children. The posterior facial height was statistically smaller than the anterior one in mouth breathing children (PFH-AFH ratio). Thus, the upper anterior facial height was statistically smaller than the lower facial height (UFH-LFH ratio).

CONCLUSION

We concluded that mouth breathing children tend to have higher mandibular inclination and more vertical growth. These findings support the influence of the breathing mode in craniofacial development.

Influência do padrão respiratório na morfologia craniofacial

OBJETIVO: este estudo teve como objetivo avaliar por meio de análise cefalométrica as diferenças nas proporções faciais de crianças respiradoras bucais e nasais. FORMA DE ESTUDO: coorte transversal. MATERIAL E MÉTODO: Foram selecionadas 60 crianças entre 6 e 10 anos que, após avaliação otorrinolaringológica para o diagnóstico do tipo de respiração, foram divididas em dois grupos: grupo I, constituído de crianças respiradoras bucais, com elevado grau de obstrução das vias aéreas e grupo II, composto de crianças respiradoras nasais. Os pacientes foram submetidos à avaliação ortodôntica por meio de radiografias cefalométricas em norma lateral, a fim de avaliar as proporções faciais, através das seguintes medidas cefalométricas: SN.GoGn, ArGo.GoMe, N-Me, N-ENA, ENA-Me, S-Go, S-Ar, Ar-Go; e os seguintes índices: iAF=S-Go / N-Me, iAFA=ENA-Me / N-Me e iPFA=N-ENA / ENA-Me. RESULTADO: Foi constatada que a inclinação do plano mandibular (SN.GoGn) nos pacientes respiradores bucais foi estatisticamente maior que nos respiradores nasais, enquanto que a proporção da altura facial posterior e anterior (iAF), e da altura facial anterior superior e inferior (iPFA) foram estatisticamente menores nos pacientes bucais, indicando altura facial posterior menor que a anterior e altura facial anterior inferior aumentada nesses pacientes. CONCLUSÃO: Pode-se concluir, então, que os respiradores bucais tendem a apresentar maior inclinação mandibular e padrão de crescimento vertical, evidenciando a influência da função respiratória no desenvolvimento craniofacial.

Estudo comparativo entre duas técnicas de tonsilectomia: bisturi harmônico (Ultracision) e dissecção tradicional com bisturi de lâmina fria

Tonsilectomia é a cirurgia realizada com maior frequência na clínica otorrinolaringológica. As modificações e as evoluções da técnica ocorrem no sentido de simplificar o procedimento e minimizar as complicações. O bisturi harmônico (Ultracision) começou a ser utilizado na Otorrinolaringologia em 1999 para tonsilectomia com bons resultados. OBJETIVO: O objetivo deste estudo foi comparar o tempo cirúrgico, sangramento e hemostasia trans-operatórios, dor pós-operatória, aspecto cicatricial da loja tonsilar e intercorrências no trans e pós-operatório em pacientes submetidos a tonsilectomia pela técnica tradicional com lâmina fria e pela técnica utilizando lâmina cirúrgica em ganchos de coagulação Ultracision. FORMA DE ESTUDO: Coorte transversal. CASUÍSTICA E MÉTODO: Vinte e seis pacientes foram submetidos a tonsilectomia: 13 pela técnica tradicional com bisturi de lâmina fria e 13 pela técnica com Ultracision, avaliando os parâmetros previamente estabelecidos através de um protocolo padrão. Os pacientes foram submetidos a uma análise da intensidade da dor através da escala analógica visual horizontal. RESULTADOS: O tempo cirúrgico foi estatisticamente menor na cirurgia realizada pela técnica com o bisturi harmônico comparada com a técnica tradicional. O percentual de pontos dados na loja tonsilar também mostrou-se mais baixo do que pela técnica tradicional. Não houve diferença significativa em relação ao padrão de dor e a evolução pós-operatória do aspecto cicatricial da loja. CONCLUSÃO: O bisturi harmônico mostrou ser um excelente recurso para a realização de cirurgias onde o tempo cirúrgico e o sangramento trans-operatório são de grande importância.

Tonsillectomy--clinical consequences twenty years after surgery?

Tonsillectomy (T) is one of the most common surgical procedures performed on children. Long-term follow-up studies concerning its consequences are lacking. This study is the first study done on a group of patients that underwent T in their childhood, about 20 years ago. The investigation is a cohort study, which followed-up 18 patients who were tonsillectomized 20 years ago. It was to be determined whether these subjects suffer from more respiratory tract infections (or other infections) today, than people who are not tonsillectomized. A group of 54 age-matched subjects were selected for comparison. A questionnaire was mailed to the study population. No significant differences were found between the groups in the frequency of upper respiratory tract infection (URI). The mean number of URI's was approximately [MSOffice1]2.5 per year in both groups. The duration of the URI's was identical in each group. A high temperature was present to the same extent in each group. Absence from work, number of visits to physicians and the use of antibiotics were the same in each group. However, the prevalence of chronic disease was greater in the T-group than in the comparison group. The difference was significant with a Relative Risk of 9.41 and a Confidence Interval differing from 1 (1.13<RR<78.14) for the T-population to develop chronic disease. Because of the small number of the present study population, the results must be validated by further immunological and epidemiological studies on long-term effects of tonsillectomy.

Crescimento pôndero-estatural de crianças após adenoamigdalectomia

A hiperplasia adenoamigdaliana é a principal causa de obstrução das vias aéreas superiores em crianças, sendo muitas vezes associada à apnéia do sono. Esta, por sua vez, resulta em uma série de comprometimentos: baixo rendimento escolar, cor pulmonale, distúrbios de comportamento não específicos, hiperatividade, sonolência diurna, distração e atrasos de desenvolvimento, sendo o déficit pôndero-estatural o mais grave. A adenoamigdalectomia é o tratamento de escolha. O objetivo deste trabalho é mensurar o crescimento e desenvolvimento das crianças antes e depois da adenoamigdalectomia através da comparação dos percentis pré e pós operatórios. FORMA DE ESTUDO: Clínico prospectivo randomizado. MATERIAL E MÉTODO: Cinquenta e cinco crianças de 2 a 12 anos, com história de obstrução das vias aéreas superiores por hiperplasia adenoamigdaliana foram submetidas a exame antropométrico (peso e altura), antes e 6 meses após a adenoamigdalectomia. Os dados foram transformados em percentil para peso e altura, de acordo com a idade e comparados através de análise estatística. RESULTADOS: No pré-operatório, encontramos a seguinte distribuição para o percentil altura: 78,2%, abaixo de p75 e para peso 70,9% abaixo de p50. No pós-operatório observou-se melhor distribuição das crianças: para altura 34,6% abaixo de p75, 32,8% entre p75-95 e 32,6% para p95 e acima e para peso: 35,5% abaixo de p50, 36,4% para p50-95 e 29,1% acima de p95. CONCLUSÃO: Observou-se uma melhora considerável do desenvolvimento pôndero-estatural das crianças após a adenoamigdalectomia.

Treatment of obstructive sleep apnea in children: do we really know how?

Obstructive sleep apnea syndrome (OSAS) is a frequent, albeit underdiagnosed problem in children. If left untreated, OSAS may lead to substantial morbidities affecting multiple target organs and systems. The immediate consequences of OSAS in children include behavioral disturbance and learning deficits, pulmonary hypertension, as well as compromised somatic growth. However, if not treated promptly and early in the course of the disease, OSAS may also impose long-term adverse effects on neurocognitive and cardiovascular function, thereby providing a strong rationale for effective treatment of this condition. This review provides a detailed description of the current treatment modalities for pediatric OSAS, and uncovers the potential limitations of the available data on these issues. Furthermore, we postulate that OSAS will persist relatively often after tonsillectomy and adenoidectomy, and that critical studies need to be conducted to identify such patients and refine the clinical management algorithm for pediatric OSAS.

Indications for tonsillectomy and adenoidectomy

OBJECTIVE

To review recent clinical trials that provide a foundation on which clinicians can base decisions regarding adenotonsillar surgery for their patients.

STUDY DESIGN

Review.

METHODS

An evidence-based approach was used to review recent clinical trials addressing indications for adenotonsillectomy, tonsillectomy, and adenoidectomy.

RESULTS

Absolute indications for tonsillectomy and adenoidectomy include adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive, or abnormal dentofacial growth; suspicion of malignant disease; and (for tonsillectomy) hemorrhagic tonsillitis. Relative indications for both procedures are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, or speech impairment, and halitosis. Otitis media and recurrent or chronic rhinosinusitis or adenoiditis are relative indications for adenoidectomy but not tonsillectomy. Recurrent or chronic pharyngotonsillitis, peritonsillar abscess, and streptococcal carriage are relative indications for tonsillectomy but not adenoidectomy.

CONCLUSION

Good clinical evidence regarding indications for tonsillectomy and adenoidectomy is available. Clinicians should make recommendations for surgery on the basis of this evidence.

Use of tonsil size in the evaluation of obstructive sleep apnoea

AIMS

(1) To determine the extent to which tonsil size contributes to the severity of obstructive sleep apnoea (OSA) in children; and (2) to assess the use of tonsillar-pharyngeal (TP) ratio in differentiating patients with different severity of OSA.

METHODS

Lateral neck radiograph was performed on 35 children referred consecutively to a university paediatric chest clinic for suspected OSA secondary to tonsillar hypertrophy. The tonsil size was determined by measuring the TP ratio on the radiographs. The severity of OSA was assessed by overnight polysomnography.

RESULTS

A total of 24 boys and 11 girls (median age 6.2 years) were studied. All presented with symptoms of OSA, and tonsillar hypertrophy was detected on clinical examination. The median apnoea-hypopnoea index (AHI) was 16.93 (interquartile range: 8.41 to 28.29). The median TP ratio was 0.76 (interquartile range: 0.65 to 0.80). AHI was positively correlated with the TP ratio. The clinical tonsil size did not correlate with the AHI or the TP ratio. Using a TP ratio of 0.479, the sensitivity and specificity in predicting cases with moderate/severe OSA (AHI >10) were 95.8% and 81.8% respectively, while the positive and negative predictive values were 92.0% and 90.0% respectively.

CONCLUSIONS

Results show that in a population of children with OSA, tonsillar hypertrophy as assessed by lateral neck radiograph correlates positively with the severity of obstructive sleep apnoea. The TP ratio has high sensitivity and specificity in predicting those with moderate/severe disease and this feature may be used as a clinical screening method in prioritising patients with OSA for further assessment.

The effects of tonsillectomy and adenoidectomy on serum IGF-I and IGFBP3 levels in children

OBJECTIVE

Obstructive adenoid and tonsillar hyperplasia may present with retardation of growth. Interruption of growth hormone-insulin-like growth factor I axis resulting from abnormal nocturnal growth hormone secretion is among the postulated causes. Growth hormone (GH) mediates its anabolic effects on tissues through insulin-like growth factor I (IGF-I). Most of the circulating IGF-I is bound to insulin-like growth factor binding protein 3 (IGFBP3). The objective of this study is to determine blood serum levels of IGF-I and IGFBP3 in patients with adenoid and tonsillar hypertrophy. Furthermore, we want to investigate the effect of tonsillectomy and adenoidectomy (T&A) on these levels.

STUDY DESIGN

The blood serum levels of IGF-I and its binding protein IGFBP3 were examined in 41 randomly selected children with a diagnosis of upper airway obstruction resulting from hypertrophic tonsils and adenoids.

METHODS

Blood samples were taken preoperatively and repeated at 3 to 6 months (mean, 4.3 mo) following T&A operation. Coated-tube immunoradiometric assay (IRMA) method was used to analyze IGF-I and IGFBP3 levels.

RESULTS

Thirty-two of 41 children were eligible for the analysis. When the preoperative and postoperative results were compared, it was found that there was a statistically significant increase in serum IGF-I and IGFBP3 levels in these 32 children (P <.001). In 7 of the 32 patients, the preoperative serum IGF-I levels were below normal. Postoperatively these levels increased within normal range. This was also statistically significant (P = .016).

CONCLUSION

These findings revealed that obstructive adenoid and tonsillar hypertrophy may cause decreased serum IGF-I levels by affecting the GH-IGF-I axis, and T&A is an effective therapeutic measure in these patients.

Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children

Thoraco-abdominal asynchrony is frequently encountered during inhalation anaesthesia in children with adenotonsillar hypertrophy causing an upper airway obstruction. The study goal was to evaluate the impact of different airway opening manoeuvres on thoraco-abdominal asynchrony as a measure of airway obstruction. Thirty anaesthetized children (aged 2-8 yrs; sevoflurane 3% in 50% oxygen/nitrous oxide) were studied prior to elective adenotonsillectomy using respiratory inductance plethysmography to record ribeage and abdominal wave forms as a basis for calculation of the phase angle. Five airway situations were compared: 1) baseline (unsupported mandible); 2) chin lift; 3) chin lift combined with continuous positive airway pressure of 10 cmH2O; 4) jaw thrust; and 5) jaw thrust combined with continuous positive airway pressure of 10 cmH2O. Three children had complete upper airway obstruction at baseline and were excluded from the study. With chin lift, thoraco-abdominal asynchrony improved in three patients, worsened in three patients and was unchanged in 21 patients. Additional continuous positive airway pressure during chin lift did not markedly reduce thoraco-abdominal asynchrony (phase angle 89 +/- 43 , p = 0.33). Jaw thrust resulted in a significant decrease of the phase angle (from 106 +/- 53 at baseline to 65 +/- 49 , p < 0.01); when combined with continuous positive airway pressure, no further effect on thoraco-abdominal asynchrony was found (72 +/- 44). In anaesthetized children with adenotonsillar hypertrophy, airway opening manoeuvres have distinct effects on thoraco-abdominal asynchrony. Delivery of continuous positive airway pressure and jaw thrust can be the first airway opening manoeuvres to improve breathing patterns. Chin lift without additional continuous positive airway pressure should be used with caution in these patients because it may convert partial into almost complete airway obstruction.

Pediatric sleep-related breathing disorders

Sleep-related breathing disorders (SRBD) can occur at any age. Obstructive sleep apnea, upper airway resistance syndrome and obstructive hypopnea syndrome all lie on the pathological continuum of SRBD. These disorders can have a great impact on a child's quality of life and can progress to significant complications. The symptoms, signs, work-up, and treatment of SRBD in children are discussed.

Pediatric obstructive sleep apnea syndrome

Pediatric obstructive sleep apnea occurs in about 2% of children, and manifests as snoring, difficulty breathing, and witnessed apneic spells. Daytime symptoms include excessive sleepiness with poor performance and behavior problems. Severe forms may be associated with failure-to-thrive or death. The gold standard diagnostic procedure is overnight polysomnography and is indicated in high-risk patients. While most pediatric patients with obstructive sleep apnea can be treated with tonsillectomy and adenoidectomy; uvulopalatopharyngoplasty, tracheotomy, or other procedures are sometimes indicated. Nonsurgical treatment with continuous positive airway pressure is used in some children. Postoperative management in high-risk children includes careful perioperative monitoring and postoperative polysomnography.

Sleep apnea treatment improves seizure control in children with neurodevelopmental disorders

Seizure disorder and sleep apnea are common chronic disorders in children, but the relationship between sleep apnea and seizure control has not been studied in the pediatric population. This retrospective review included nine children with neurodevelopmental disorders who had well-documented sleep apneic episodes and seizure disorders. Seizure frequency was reduced in five patients (56%) in the first 12 months after sleep apnea treatment without changes in their antiepileptic medications. Sleep apnea can be one of the seizure precipitants in children with epilepsy. This study indicates the importance of identifying sleep apnea when treating children with intractable epilepsy, particularly in those who are at high risk.

Tonsil and Adenoid Surgery for Upper Airway Obstruction in Children

We studied the outcomes of 76 children, aged 3 to 12 years, with large tonsils and/or large adenoids who underwent surgery to relieve upper airway obstruction over a 1-year period. Following surgery, nearly all patients experienced an alleviation of all symptoms, except for enuresis. We suggest that children who have large tonsils and/or adenoids will gain substantial benefit if they are removed, even children who do not have a history of severe sleep apnea or objective evidence from polysomnography.

Body growth in relation to tonsillar enlargement

Severe airway obstruction caused by tonsillar enlargement can result in disturbances in body growth. In this study, 1136 children between 7 and 12 years of age, were evaluated and the size of their tonsils was investigated with regard to height and weight. This study was performed in the course of school screening, and correlation between estimated tonsil size and height and weight of the children was sought. Statistically, no such correlation was found (P > 0.05).

Tonsillectomy and adenoidectomy. Changing indications

Obstructive sleep apnea and upper airway obstruction (even without complete apnea) from adenotonsillar hypertrophy is either occurring more frequently or is becoming better recognized. Tonsillectomy or adenoidectomy is indicated for these children. Most patients who would benefit from surgery can be identified by a thorough history and physical examination. Occasionally, additional methods of evaluation, such as lateral neck radiographs or polysomnograms, are helpful. The indications for tonsillectomy and adenoidectomy are varied. No review can cogently encompass all clinical scenarios. Tonsillectomy and adenoidectomy remain valuable procedures for carefully selected patients.

Changes in deglutition following tonsillectomy in neurologically impaired children

Tonsillectomy for improvement of dysphagia in children is well recognized, but its effects upon deglutition in the neurologically impaired child have not been described. A review was performed of pre- and post-operative oral-pharyngeal motility (OPM) studies obtained on 15 children (aged 1-10 years; mean 4.6 years) with neurologically-based dysphagia who underwent tonsillectomy for upper airway obstruction (13) or recurrent tonsillitis (2). Each OPM study was rated independently by two trained observers for the presence or absence of 13 features of deglutition. Subjects served as their own control in comparative analysis. There was a mean improvement of 4.33 features of deglutition (mode: 4, range: -1(-)+7) following tonsillectomy. Of 10 children with pre-existing laryngeal penetration or aspiration, two had partial resolution and five had complete resolution following surgery. Post-operatively, two children developed new laryngeal penetration with one also having aspiration. The inter-observer reliability for the OPM study interpretation was 0.90. We conclude that tonsillectomy has a role in the neurologically impaired child with dysphagia, but a pre-operative OPM study is indicated to identify silent aspiration and to aid in necessary counseling for the possibility of a deterioration of deglutition following surgery.

Overnight pulse oximetry in normal children and in children undergoing adenotonsillectomy

This study investigates the hypoxia that has been described during sleep in children admitted for adenotonsillectomy. Two hundred and twenty-two randomly selected children and 33 children awaiting adenotonsillectomy had overnight pulse oximetry performed at home. Children undergoing surgery had a second study in hospital on the eve of surgery and a third at home 3 months post-operation. Analysis of pulse oximetry data failed to detect a clinically significant difference in oxygen saturation levels between these populations. Snoring is reported in 76% of children undergoing adenotonsillectomy and 11% of the normal population. Sleep apnoeic episodes occur in 52% of children prior to surgery compared with 8% of the normal population. Overnight pulse oximetry has failed to differentiate children with symptoms suggestive of obstructive sleep apnoea from the normal population. Its use as a screening procedure should be used with caution until more is known about its ability to predict significant disease.

Computer assisted pulse oximetry for detecting children with obstructive sleep apnea syndrome

A prospective study was carried out on 110 children undergoing tonsillectomy or adenotonsillectomy to evaluate the usefulness of computer assisted pulse oximetry (POM) as a screening tool for nocturnal obstructive sleep apnea episodes. Twenty-one healthy age-matched children served as a control group. A self-designed software (CAPO version 1.0) was used to analyse collected oximetric data. Pre-operatively up to 25% of children showed a characteristic pattern of repeated oxygen desaturations related to partial or complete airway obstruction, which was not seen in the matched group. Thirty-one percent had an oxygen desaturation index (ODI) of more than 2 phases/h, being significantly higher than in the matched group. These children could not be identified from history or clinical examination with an acceptable sensitivity. A second monitoring has been performed in 32 patients 5 days after surgery. The nocturnal cyclic oscillations of oxygen saturation resolved in almost all cases. Computer assisted POM is useful in predicting and grading nocturnal obstruction and adds decision making data for the treatment in children suspected of suffering from obstructive sleep apnea.

Sleep-related breathing disorders. 6. Obstructive sleep apnoea syndrome in infants and children: established facts and unsettled issues

The presence of increased upper airway resistive loads during sleep can now be diagnosed by paediatricians. However, diagnostic criteria need to be further clarified to allow accurate identification of episodes of partial airway obstruction. New technological advances can be expected to help to determine the clinical usefulness of ambulatory testing during sleep and thus to establish the indications for polysomnographic investigations in the laboratory. A thorough investigation of the anatomical abnormalities that contribute to airways obstruction is essential for selecting the most appropriate therapy. However, the order in which these investigations should be performed remains unclear. The diagnostic tools, including questionnaires and sleep testing, and methods aimed at investigating pathophysiological mechanisms should be standardised for multicentre studies. Familial factors should be taken into account. The best strategy for preventing the complications of the OSA syndrome is to identify the disorder as early as possible. This requires close cooperation between adult physicians and paediatricians called upon to evaluate sleep-related disorders.

The epidemiology of sleep related breathing disorder in children

An epidemiological study of sleep obstruction and its orthodontic consequences is under way on a cohort (500) of 4-year-old children. The parents are asked about the child's snoring, sleep apnea, sucking habits, infections and 'genetic clues'. Dental casts have been made from the first 100 children and the group of children who snore are being compared to the non-snorers. A sleep study, a lateral cephalogram and dental casts are done on all snorers in the cohort. Preliminary results show that 6.2% snore every night by age 4 and another 18% when infected. More children use pacifiers among the snorers than in the non-snoring group (60% vs. 35%). Tonsillar angina is 3 times more common in the snorer group and twice as many of their parents have been adenoidectomized (A) and/or tonsillectomized (T). The dental casts show a significant difference in width of the maxilla and length of the mandible. The children are treated for their breathing obstruction with A or A+T. Two years later, the same cohort will be examined again. The prevalence of snoring and sleep apnea among 4-year-olds will be known as will whether and how treatment for breathing obstruction influences facial development.

The influence of tonsillectomy on obstructive sleep apnea children with malocclusion

Adeno-tonsillar hypertrophy is the most common cause of obstructive sleep apnea syndrome (OSAS) in childhood and may also play a role in the development of craniofacial abnormalities. The mode of breathing and the morphology of the dental arch are very closely connected. Most of the children who came to the ENT clinic had malocclusions. The early performance of surgical treatment on hypertrophied tonsils and/or adenoids influenced greatly the state of health and morphology of the dental arch. In the process of diagnosis and treatment of children with OSAS it is necessary to have multidisciplinary cooperation, especially between the otolaryngologist and the orthodontist.

Body growth in relation to tonsillar enlargement and tonsillectomy

Severe airway obstruction caused by tonsillar enlargement can result in disturbances in body growth. The effect of this interference and of tonsillectomy in the child with only moderate symptoms have been less satisfactoril evaluated. In this study, 122 children with symptoms and signs of tonsillar obstruction were investigated concerning the height and weight before and after tonsillectomy. None of the individuals demonstrated cardiopulmonary complications of tonsillar obstruction. Altogether 10% of the children exhibited abnormalities in body weight and/or length prior to surgery. Especially during the first postoperative year, the weight and height gain exceeded the expected in 75% of the patients. The accelerated weight gain increased with tonsil size, but there was no relation to the extent of difficulties in swallowing or sleeping disruptions. The results support the hypothesis that tonsillar hypertrophy frequently is associated with disturbances in body growth and that this is seldom demonstrable prior to tonsillectomy.

The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology

Children, who were tonsillectomized because of sleep apnea were examined with respect to facial growth and dental arch morphology. Dental casts and lateral roentgencephalograms were analysed before surgery and two years after tonsillectomy. The findings were compared to data from children without tonsillary obstruction. A higher proportion of malocclusion than normal, especially open bite and crossbite, was noticed before surgery. Two years after surgery, 77% of the open bites were normalised and 50-65% of the buccal and anterior crossbites. The best results were seen in children operated before the age of 6.

Down syndrome and sleep apnea--a therapeutic challenge

This case report describes 3 patients with Down syndrome and obstructive breathing problems, ages: 5 months, 15 months, and 22 years. The youngest one had normal cardiopulmonary function at birth, but soon developed a pulmonary hypertension. The next had a severe atrioventricular defect and additional pulmonary hypertension and there was little hope for her to survive heart surgery. The oldest one had had apneas since childhood with increasing severity, but was regarded as having normal heart function. All 3 were operated to relieve their breathing obstruction. The 5-month-old boy improved only slightly after an initial UPPP and had to be tracheotomized, which solved his problems. The tracheotomy could be removed when he was one year. The 15-month-old girl was cured of her breathing problems through an A + T and survived her heart surgery one month later. Tonsillectomy and UPPP was performed on the oldest patient. Following surgery, he had an episode of life-threatening bleeding and developed a DIC syndrome, and was critically ill for 18 days. After he recovered, his sleep apnea had improved. Once a myxoedema was diagnosed and treated, he made further progress. These cases stress the significance of early recognition of sleep apnea in children with Down syndrome and the importance of a careful preoperative investigation in collaboration with cardiologists.

Sleep apnea in children without hypertrophy of the tonsils

Two 12-year-old boys with severe sleep apnea syndrome but normal-sized tonsils were satisfactorily corrected by tonsillectomy and uvulopalatopharyngoplasty. One of the boys had muscular hypotony as contributing cause of the condition. The other had mandibular hypoplasia in combination with a long soft palate. Thorough preoperative anamnesis and examination in a sleep laboratory are necessary to determine which cases will benefit from surgery in spite of normal-sized tonsils and which surgical procedure will be most helpful.