Changes in serum IGF-1 and IGFBP-3 levels and growth in children following adenoidectomy, tonsillectomy or adenotonsillectomy

Objective

The aim of this study is to determine the effect of adenoidectomy, tonsillectomy or adenotonsillectomy on growth. For this purpose, we prospectively reviewed the postoperative changes in serum levels of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3), weight and height in children that underwent adenoidectomy, tonsillectomy or adenotonsillectomy.

Methods

Ninety-six children with symptoms of sleep disordered breathing (SDB) or recurrent adenotonsillitis were enrolled to study. Blood samples were taken preoperatively and repeated at 6 months following operation to determine the changes in serum IGF-1 and IGFBP-3 levels, pre- and postoperative values of weight and height were recorded for each operation.

Results

Thirty-six patients underwent adenoidectomy, 52 patients underwent adenotonsillectomy and 8 patients underwent tonsillectomy. Seventy of the operations were performed for SDB and 26 were performed for recurrent adenotonsillitis. The mean serum levels of IGF-1 increased by 26%, from 126.74 ± 112.13 ng/ml to 159.82 ± 122.91 ng/ml (p < 0.001) and IGFBP-3 levels increased by 7%, from 3.34 ± 1.17 μg/l to 3.57 ± 1.16 μg/l (p < 0.05) 6 months after operation. The increase was independent from the preoperative diagnosis. There was a significant increase both in patients with SDB and in children with recurrent infections (p < 0.001 for IGF-1, p < 0.05 for IGFBP-3). Their Z scores (standard deviation scores) for body weights (mean Z score from −0.06 ± 0.98 to 0.118 ± 1.18, p < 0.001) and heights (mean Z score from 0.30 ± 0.98 to 0.42 ± 0.88, p < 0.001) were significantly higher 6 months after the operation compared to preoperative period.

Conclusions

We found a significant increase in weight, height, and IGF-1 and IGFBP-3 levels of children with SDB or recurrent infections postoperatively. These results suggest that upper airway obstruction may not be the only mechanism that causes retardation on growth in children.     

A comparison of two transfusion regimens in the perioperative management of children with sickle cell disease undergoing adenotonsillectomy

Adenotonsillar hypertrophy and chronic tonsillitis are common findings in patients with sickle cell disease (SCD). Various preoperative transfusion regimens have been suggested to reduce the population of sickle erythrocytes and correct the anemia, ranging from conservative (correcting the anemia) to aggressive (lowering the level of HbS to less than 30%). A total of 39 patients with SCD were included in the study. They were divided into 2 groups. Fourteen patients in group 1 were assigned aggressive exchange transfusion and 25 patients in group 2 were assigned a conservative (simple) transfusion. The 2 groups were compared for possible operative and postoperative complications. Thirty percent of patients in both groups had postoperative complications. They ranged from mild local infection to acute chest syndrome. Simple transfusion was not associated with higher incidence of complications and resulted in only one-third as many transfusion requirements.     

腺样体扁桃体切除术对睡眠呼吸紊乱患儿生活质量的影响

目的：评价阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患儿行扁桃体和（或）腺样体切除手术治疗前后生活质量的改善程度，并与有睡眠呼吸紊乱（SDB）症状但整夜PSG阴性的患儿进行比较；同时分析PSG与疾病特异性生活质量调查结果之间的相关性。方法：SDB患儿术前1～2周内行整夜PSG监测，根据结果分为PSG阳性组和阴性组，术后6～9个月内进行随访。使用儿童OSAHS疾病特异性生活质量调查量表（OSA-18）对患儿术前及术后的生活质量进行评估，比较2组患儿术后生活质量改善情况。对PSG确诊的OSAHS患儿，分析术前整夜PSG与OSA-18指标之间的相关性。结果：共51例患儿入选，其中28例整夜PSG结果达到OSAHS诊断标准（阳性组），另23例为PSG阴性组。2组的临床资料具有可比性。术前OSA-18评分在2组之间的差异无统计学意义。术后2组患儿的OSA-18总分及各维度评分较术前均明显降低（均P〈0．01），且术前、术后评分的变化值2组比较差异无统计学意义（P〉0．05）。在PSG确诊的OSAHS患儿，术前AHI与OSA-18量表中睡眠障碍、身体症状和对监护人影响3个维度的评分有明显相关性（均P〈0．01），而与总分及其他2个维度无显著相关（均P〉0．05）。结论：对整夜PSG确诊的OSAHS患儿，扁桃体和（或）腺样体切除术后整夜PSG指标显著改善伴随生活质量明显提高，但没有发现术前OSA-18量表评分与整夜PSG检测指标之间有显著相关性。对有睡眠呼吸紊乱症状而其他方面健康的患儿，即使整夜PSG阴性，也能从手术治疗中受益。     

舒芬太尼与瑞芬太尼用于儿童扁桃体和腺样体切除术后麻醉恢复质量的比较

目的 观察舒芬太尼与瑞芬太尼在儿童扁桃体和腺样体切除术中及术后镇痛镇静作用,比较两种药物对麻醉恢复质量的影响.方法 选择择期进行扁桃体和腺样体切除术患儿80例,随机分为舒芬太尼组(S组,n=40)和瑞芬太尼组(R组,n=40).S组以舒芬太尼0.2μg/kg快速诱导,以0.2μg·kg-1·h-1术中维持,手术结束前30分钟停药.R组以瑞芬太尼2μg/kg快速诱导,以6μg·kg-1·h-1术中维持,手术结束前5分钟停药.分别观察两组术中术后血流动力学指标及术后患儿镇痛镇静程度.结果 两组在术中血流动力学指标无明显差异(P＞0.05).拔管后5分钟时S组MAP较基础值无明显差异;R组MAP较基础值明显增高(P＜0.05).S组患儿在术后Ramsay评分较适宜,VAS评分较低.结论 两种药物均适用于儿童扁桃体和腺样体切除术,舒芬太尼可提高术后麻醉恢复质量.     

重视阻塞性睡眠呼吸暂停低通气综合征儿童腺样体

儿童阻塞性睡眠呼吸暂停低通气综合征(OSAS)是常见的儿童睡眠呼吸疾病。OSAS对儿童体格、神经认知发育、心血管系统以及内分泌代谢水平都可能产生危害。腺样体、扁桃体肥大是儿童OSAS的主要病因,腺样体、扁桃体切除术(T&A)因而是治疗儿童OSAS的一线治疗方法。多数接受T&A治疗的儿童睡眠呼吸障碍有显著改善,但按照研究定义的不同,儿童T&A术后OSAS残留的发生率在21.6%~49.0%之间。一些儿童存在术后OSAS残留的危险因素,对这些患儿后续的监测和管理有助于纠正残留疾病导致的病理生理危害及并发症。就腺样体、扁桃体切除术后残留的危险因素以及后续检查、治疗做一综述,旨在加强对儿童OSAS术后随访和管理的重视,提高儿童睡眠疾病的整体诊断和治疗水平。     

Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy

OBJECTIVE: To determine whether a subtotal bovie tonsillectomy decreases postoperative pain following adenotonsillectomy. METHODS: A prospective, randomized, double-blinded clinical trial was undertaken at a University Pediatric Children's Hospital and included 39 otherwise healthy children, aged 2-12 years, undergoing adenotonsillectomy. Patients were randomized to receive either a subtotal or total removal of the tonsils utilizing an electrocautery technique. The main outcome measures included a visual analog scale (VAS) at rest and while eating, time to take 100 cm(3) of fluid, throat, neck, and ear pain, quantity of liquids, activity level and incidence of emesis and retching. RESULTS: A repeated measures analysis using a repeated measures ANOVA failed to demonstrate a statistically significant impact with either treatment for VAS at rest or while eating (p=0.52 and 0.48, respectively). A repeated measures analysis did not show either procedure significantly affecting throat, neck or ear pain, or liquid quantity. Time to take 100 cm(3) liquids and the incidence of emesis or retching were found not to be statistically significantly different between the treatment groups. CONCLUSION: Subtotal tonsillectomy via an electrocautery technique does not reduce postoperative pain or improve outcome parameters. Subtotal tonsillectomy with this technique is not recommended for this patient population.     

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.     

Preoperative continuous positive airway pressure compliance in children with obstructive sleep apnea syndrome: assessed by a simplified approach

INTRODUCTION: The frequency of diagnoses of obstructive sleep apnea syndrome (OSAS) in children is increasing and more and more adenotonsillectomies (A&T) are being performed on severely ill children who have a higher perioperatory risk. The objective of the present study was to describe preoperative compliance in the use of continuous positive airway pressure (CPAP) in children with OSAS, when this treatment was prescribed as a means of preventing complications. PATIENTS AND METHODS: We describe data from children with severe OSAS caused by hypertrophy of the adenoids and tonsils, but with no craniofacial abnormalities. CPAP pressure was adjusted either during diurnal polysomnography with sleep deprivation or by self-adjusting devices. Follow-up was conducted through weekly interviews and the downloading of data recorded by the equipment. RESULTS: 48 children were included; 73% of them used a CPAP machine > or =3h per night, and 31% used it for > or =6h per night. The variables associated with good equipment compliance included higher BMI, higher pressure levels in the devices, and a higher number of episodes of apneas and hypopneas. Children who weighed > or =30kg used CPAP for > or =3h per night more often (OR 16, 95% CI 1.9-137). Compliance levels with fixed and self-adjusting CPAP were similar, and side effects in both cases were slight and limited to those caused by the pressure of the masks on patients' skin. One case of excessive bleeding was the only complication reported during A&T. CONCLUSIONS: The mean preoperative use of CPAP equipment by children with severe OSAS was 4.5+/-2.6h. Seventy-three percent of subjects used the equipment for >/=3h.