腺样体扁桃体切除术治愈儿童阻塞性睡眠呼吸暂停综合征的偏误研究

阻塞性睡眠呼吸暂停综合征（OSAS）在我国儿童中的发病率分别为男童5.8%和女童3.8%，会影响儿童正常的生长发育，导致儿童生长迟滞、神经认知缺陷、智力发育及行为异常等问题，因此早期识别与诊断并进行适当的早期治疗至关重要。儿童OSAS的治疗方法多种多样，从内科的药物治疗到外科的手术治疗，从耳鼻咽喉的专科治疗到多学科联合治疗，治疗效果参差不齐，公认的一线治疗仍然是手术，而手术又以腺样体扁桃体联合切除术（AT）为主流。AT术后疗效及并发症众说纷纭，有学者认为AT治疗儿童OSAS疗效显著，症状可完全缓解；另有一部分学者则认为AT治疗儿童OSAS的疗效有待商榷，术后并发症及残余疾病很难避免，AT还不足以治愈OSAS患儿。对儿童OSAS的AT治疗进行阐述，以期为临床治疗儿童OSAS提供参考。     

Airway obstruction in children with cerebral palsy: Need for tracheostomy?

Objective

To examine the progress of the airway obstruction over time in children with cerebral palsy (CP) and the timing of any interventions.

Methods

The medical notes of patients with CP younger than 16 years admitted with airway obstruction to a tertiary referral Pediatric Otolaryngology Center from 2006 to 2012 were retrospectively reviewed. The gender, age of referral, co-morbidities, type of surgical intervention and age this was performed and the time interval between sequential surgeries were documented.

Results

Fifteen children with CP and airway obstruction were admitted, eight boys and seven girls with an average age of referral 8 years (range 3–13.3 years). Adenotonsillectomy was performed in 11/15 patients at a mean age of 9.1 years (range 4.5–14 years). Tracheostomy was performed in 8/15 children at an average age of 11.6 years (range 7.5–15 years). Seven out of 11 patients having undergone adenotonsillectomy, required tracheostomy after an average time interval of 1.9 years (range 0.5–3.5 years). Tracheostomy was performed in 80% of referred patients with CP older than 10 years, while surgical intervention was uncommon in children younger than 5 years. There was a statistically significant correlation between the age of the children and the performance of a tracheostomy (Pearson's correlation coefficient 0.68, p = 0.005).

Conclusions

The severity of the airway obstruction in children with CP tends to increase with age. We postulate that this increase results from worsening hypotonia of pharyngeal musculature. Children with CP and severe upper airway obstruction are likely to require tracheostomy as they grow older.     

Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3–6 year old children undergoing adenotonsillectomy

IntroductionAdenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3–6 years with caregiver-reported symptoms.MethodsChildren 3–6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.ResultsThe cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = −0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.ConclusionSubjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3–6 years of age undergoing adenotonsillectomy.     

Late-onset laryngomalacia: a cause of pediatric obstructive sleep apnea

Objective

To describe the presentation, diagnosis, and treatment of late-onset laryngomalacia in children with obstructive sleep apnea syndrome (OSAS).

Design

Retrospective study.

Setting

Tertiary care children's hospital.

Patients

Seventy-seven children were identified who had OSAS diagnosed by polysomnography and underwent airway endoscopy to evaluate for laryngomalacia between July 2006 and December 2008. Children with significant neurologic disease or craniofacial malformations were excluded. Seven children under 3 years of age had laryngomalacia and OSAS (Group A), 19 children 3-18 years of age had laryngomalacia and OSAS (Group B), and 51 children 3-18 years of age had OSAS but not laryngomalacia (Group C).

Main outcome measures

Comparison of pre-operative findings, intra-operative findings, interventions, and outcomes between the 3 groups.

Results

Group A was consistent with previous reports of congenital laryngomalacia with respect to presentation, diagnosis, and treatment. Groups B and C had similar pre-operative findings, including a high incidence of adenotonsillar hypertrophy, and the only significant difference was the intra-operative finding of laryngomalacia in Group B. Treatments were individualized to include supraglottoplasty, adenoidectomy, tonsillectomy, adenotonsillectomy, or a combination of the above. Of the 52 patients who returned in follow-up, 44 noted improvement, but this was rarely confirmed by polysomnogram.

Conclusions

Late-onset laryngomalacia may act alone or in concert with additional dynamic or fixed lesions to cause pediatric OSAS. Although there is no specific pre-operative indicator to diagnose late-onset laryngomalacia, it can be readily identified intra-operatively and effectively treated with supraglottoplasty, with or without concurrent adenotonsillectomy.     

Trends in the indications for pediatric tonsillectomy or adenotonsillectomy

Objective

To report trends in the indications for pediatric tonsillectomy or adenotonsillectomy.

Methods

To identify current indications, (1) a retrospective chart review analyzed all indications for procedures performed by a pediatric otolaryngologist on patients aged 0-3, 4-10, or 11-18 years, and (2) a cross-sectional survey to members of the American Society of Pediatric Otolaryngology asked for approximate percentages of children in the same age groups receiving procedures for obstruction, infection, or another indication. To assess changing indications over time, (3) a literature review was performed.

Results

(1) Chart review: 302 patients aged 5 months to 18 years (average: 6.34; median: 6) were analyzed. For the 0-3-year age group, obstruction was an indication in 100.0% of cases, and infection in 2.6%. For the 4-10-year age group: 91.9% and 13.4%, respectively. For the 11-18-year age group: 84.6% and 33.3%. (2) Survey: 120 surveys were returned (40% response rate), and 63 surveys were appropriate for analysis (21% completion rate). For the 0-3-year age group, obstruction was the primary indication in 91.8% of procedures and infection in 7.5%. For the 4-10-year age group: 73.2% and 25.3%, respectively. For the 11-18-year age group: 43.0% and 54.2%. (3) Literature review: 11 articles consistently illustrated a rise in obstruction and a decline in infection as an indication since 1978.

Conclusions

Obstruction has become a more prominent indication than infection for pediatric tonsillectomy or adenotonsillectomy in children, especially younger children. Infection becomes a more prominent indication as age increases. Data may not be absolutely reflective of all pediatric otolaryngologists or other otolaryngologists that treat children. Comparing studies is difficult owing to the variety of surgical procedures focused upon and terms used to define indications.     

Guidelines to decrease unanticipated hospital admission following adenotonsillectomy in the pediatric population

Introduction

Tonsillectomy has become one of the most commonly performed surgical procedures in the pediatric-aged patient. Many of these children are diagnosed with obstructive sleep apnea (OSA). Although polysomnography is considered the gold standard, many practioners rely on the clinical examination and parental history. Nationwide Children's Hospital recently instituted pediatric adenotonsillectomy guidelines for hospital admission to help determine which patients should be done in main hospital OR vs. outpatient surgery facility. The main goal was to decrease unanticipated admissions. The secondary goal was to determine areas for practice improvement.

Methods

Using databases for the hospital, operating room, and otolaryngology, all cases with CPT codes 42820, 42830, 42825, 42826, and 42821 were evaluated from October 2009 to August 2012 in the main operating room and 2 outpatient surgery centers. Data for each unanticipated admission were reviewed to determine whether the criteria were met according to the developed guidelines. Fisher's exact test was applied to the unplanned admission rate before and after the institution of the guidelines. Non-paired t-test and a Fisher's exact test were used for comparison of the demographic data between the two groups.

Results

Following the institution of the pediatric adenotonsillectomy guidelines, the number of unanticipated admissions decreased from an absolute number of 88 to 43. This represents a decrease from 2.38% to 1.44% (p = 0.008). Forty-two percent of the unanticipated admissions prior to establishing guidelines were in patients who would have met criteria for admission based on the guidelines. This decreased to 30% after establishing the guidelines.

Conclusion

We found that the institution of pediatric adenotonsillectomy guidelines for patients undergoing adenotonsillectomy significantly decreased the rate of unanticipated admission. However, there was still a significant percentage (30%) of unanticipated admissions due to non-compliance with the guidelines demonstrating the need for ongoing practice improvement.     

Is day stay adenotonsillectomy safe in children with mild to moderate obstructive sleep apnoea? A retrospective review of 100 patients

Objective

This study explored the perioperative course of 100 children with polysomnogram (PSG) proven mild to moderate OSA to evaluate if day stay adenotonsillectomy is safe.

Methods

A retrospective chart review of patients who had undergone tonsillectomy with or without adenoidectomy following an overnight PSG at The Children's Hospital at Westmead Sleep Laboratory. 263 records were reviewed. Patients with apnoea hypopnea index (AHI) ≥1 and <15/h and/or a final sleep study report of mild to moderate OSA were included. Exclusion criteria were age <3 years, weight <10 kg, or any significant co-morbidities or other surgery that would preclude day stay surgery. Demographic, PSG and post-operative data was analyzed.

Results

No major respiratory complications occurred. No patient required an unplanned medical review for respiratory concerns, or admission to a high care facility. Eleven children left recovery with oxygen prescribed. One child had a desaturation to 88% in recovery, and one child had laryngospasm. The nine other children required oxygen to maintain saturation >90%.Supplemental oxygen was prescribed to 7 patients on the ward. Of these, three patients received supplemental oxygen beyond 6 h. The other 97 patients had an uncomplicated post-operative course and would have been suitable for day-stay surgery. Increasing severity of OSA grade on pre-operative PSG was significantly associated with post-operative supplemental oxygen use (p = 0.003; Cochrane-Armitage test for trend).

Conclusions

Children who are otherwise well with mild to moderate OSA have a sufficiently low risk of respiratory complications following adenotonsillectomy to permit day-stay surgery in the setting of appropriate facilities with careful post-operative monitoring for the first 6 h to identify a small sub-group who require overnight observations.     

An audit of the use of an opiate sparing,multimodal analgesic regime in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy

Objectives

Children with Sleep Disordered Breathing/Obstructive Sleep Apnoea have an increased incidence of respiratory complications following adenotonsillectomy. This may be partly related to an increase in sensitivity to opiates.An audit of such cases undergoing adenotonsillectomy was performed with the following aims:

1.

To measure and compare the incidence of postoperative respiratory complications following an already locally established opiate sparing, multimodal analgesic regime, with published reports.

2.

To measure local compliance with these guidelines.

3.

To consider which risk factor(s) best predicted the chances of a respiratory complication occurring, perhaps enabling a more efficient use of post operative resources in the future.

4.

To measure the incidence of postoperative haemorrhage and post operative nausea and vomiting.

Methods

All patients had Sleep Disordered Breathing/Obstructive Sleep Apnoea confirmed preoperatively by Overnight Oximtery Studies. Oximetry data was expressed as the lowest recorded saturation (SpO_2 Low %) and number of significant desaturations (see text) per hour (ODI4%). Case notes and oximetry studies were scrutinized for relevant perioperative anaesthetic and analgesic data, risk factors and complications.

Results

The overall incidence of major and minor respiratory complications was low (1.6% and 27% respectively). Children who suffered any complication were more likely to be younger (p = 0.0078), have a lower SpO_2 Low (p = 0.004) and higher ODI4% (p = <0.0001). Multiple logistic regression showed ODI4% to be the best predictor of a potential respiratory complication (p = 0.0032). An ODI4% of >8 may be the best cut off point in predicting complications (AUC = 0.78, sensitivity = 0.90) but it showed a poor specificity (0.57). Primary/secondary haemorrhage occurred in 0.4%/1.2% respectively and postoperative nausea and vomiting in 4.4%.

Conclusions

A low dose opiate-based, multi modal analgesic regime appears to be effective and safe in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy.     

Respiratory viruses are continuously detected in children with chronic tonsillitis throughout the year

Objective

To evaluate the oscillations on the viral detection in adenotonsillar tissues from patients with chronic adenotonsillar diseases as an indicia of the presence of persistent viral infections or acute subclinical infections.

Study design

Cross-sectional prospective study.

Setting

Tertiary hospital.

Methods

The fluctuations of respiratory virus detection were compared to the major climatic variables during a two-year period using adenoids and palatine tonsils from 172 children with adenotonsillar hypertrophy and clinical evidence of obstructive sleep apnoea syndrome or recurrent adenotonsillitis, without symptoms of acute respiratory infection (ARI), by TaqMan real-time PCR.

Results

The rate of detection of at least one respiratory virus in adenotonsillar tissue was 87%. The most frequently detected viruses were human adenovirus in 52.8%, human enterovirus in 47.2%, human rhinovirus in 33.8%, human bocavirus in 31.1%, human metapneumovirus in 18.3% and human respiratory syncytial virus in 17.2%. Although increased detection of human enterovirus occurred in summer/autumn months, and there were summer nadirs of human respiratory syncytial virus in both years of the study, there was no obvious viral seasonality in contrast to reports with ARI patients in many regions of the world.

Conclusion

Respiratory viruses are continuously highly detected during whole year, and without any clinical symptomatology, indicating that viral genome of some virus can persist in lymphoepithelial tissues of the upper respiratory tract.     

扁桃体腺样体切除术对睡眠呼吸障碍儿童血清C反应蛋白的影响

目的:探讨扁桃体腺样体切除术对睡眠呼吸障碍（SDB）儿童全身炎症的治疗作用。方法:采用多导睡眠仪,对65例睡眠打鼾儿童进行整夜睡眠监测,并应用conners简明症状问卷评定儿童行为问题。比较阻塞性睡眠呼吸暂停低通气综合征（OSAHS）与单纯鼾症儿童行手术前和手术1年后血清C反应蛋白水平的变化以及异常行为的改善情况。结果:无论血清C反应蛋白含量还是Conners行为简明症状问卷得分在OSAHS儿童明显高于单纯鼾症及健康对照儿童;单纯鼾症儿童也明显高于健康对照组。在OSAHS组Conners行为简明症状问卷评分由行扁桃体腺样体手术前的14.2±3.8下降到手术后6.7±3.1,血清C反应蛋白含量由术前的(4.25±1.78)mg/L下降到术后的(3.23±1.45)mg/L(P<0.05),差异有统计学意义;单纯鼾症组Conners行为简明症状问卷评分由术前的9.4±4.1下降到术后5.1±2.8,血清C反应蛋白含量由术前的(2.77±1.80)mg/L下降到术后的(1.76±0.81)mg/L(P<0.05),差异有统计学意义。结论:SDB儿童有较多的行为问题出现以及较高的血清C反应蛋白水平。扁桃体腺样体切除术对SDB儿童行为异常有明显的治疗作用,同时血清C反应蛋白水平也明显的下降。