Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea

BackgroundIntracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited.ObjectiveTo examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA.MethodsA retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO₂), and surgical complications.ResultsOf the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy.ConclusionsIntracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.     

儿童扁桃体切除术后出血率及出血程度分级的初步探讨

目的　统计儿童扁桃体切除术后出血率,根据Windfuhr分级法衡量儿童扁桃体术后出血的程度。方法 统计2010年3月～2013年3月在深圳市儿童医院行扁桃体切 除或扁桃体加腺样体切除患儿资料,统计术后出血发生率。结果　1672例患儿扁桃体切除术后出血16例,出血率为0.96%。女童术后出血率1.8%明显高于男童出血率0.53%,差异有统计学意义（χ 2=5.545,P <0.05）;原发性出血6例,继发性出血10例。出血程度1级9例,2级7例。结论 儿童扁桃体切除术后出血率很低,遇有活动性出血者应手气管插管全麻下止血。     

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.     

Polysomnography outcomes for partial intracapsular versus total tonsillectomy

Objective

To demonstrate similar improvement in pediatric sleep-disordered breathing (SDB) as determined by polysomnography (PSG) with microdebrider-assisted partial intracapsular tonsillectomy and adenoidectomy (PITA) versus Bovie electrocautery complete tonsillectomy and adenoidectomy (T&A).

Methods

In this retrospective cohort study, 30 children found to have SDB by PSG who have undergone either PITA (15 participants) or T&A (15 participants) as treatment were evaluated with standardized history and physical examination and unattended home overnight PSG.

Results

Median change in apnea-hypopnea index (AHI) was 1.7 (−4.9 to 29.8) for the PITA group and 2.3 (−10.9 to 64.1) for the T&A group, although there was substantially more variability in the T&A group. A mixed linear model evaluating the relation of surgical group with change in AHI demonstrated no significant differences in group means (F[1,13] = 0.31, P = .590) but the variances differed significantly (residual likelihood ratio chi-square = 5.24, df = 1, P = .022). Five of 15 (33%) PITA patients and 4 of 15 (27%) T&A patients had postoperative AHI scores of ≤5; this difference was not statistically significant (Fisher exact test P = 1.000). There was no significant interaction or substantial confounding effect of age, sex, race, preoperative tonsil size, preoperative AHI, or body mass index in the model relating surgery type to reduction of postoperative AHI to ≤5.

Conclusions

Our study demonstrates no clinically or statistically significant differences in PSG and clinical outcomes between PITA and T&A for treatment of pediatric SDB in otherwise healthy children.     

Sleep disordered breathing: surgical outcomes in prepubertal children

OBJECTIVE: To evaluate the treatment outcomes of sleep disordered breathing (SDB) in prepubertal children 3 months following surgical intervention. STUDY DESIGN: Retrospective investigation of 400 consecutively seen children with SDB who were referred to otolaryngologists for treatment. METHOD: After masking the identities and conditions of the children, the following were tabulated: clinical symptoms, results of clinical evaluation and polysomnography at entry, the treatment chosen by the otolaryngologists, and clinical and polysomnographic results 3 months after surgery. RESULTS: Treatment ranged from nasal steroids to various surgical procedures. Adenotonsillectomy was performed in only 251 of 400 cases (68%). Four cases included adenotonsillectomy in conjunction with pharyngoplasty (closure of the tonsillar wound by suturing the anterior and posterior pillar to tighten the airway). Persistent SDB was seen in 58 of 400 children (14.5%), and an additional 8 had persistent snoring. Best results were with adenotonsillectomy. CONCLUSION: SDB involves obstruction of the upper airway, which may be partially due to craniofacial structure involvement. The goal of surgical treatment should be aimed at enlarging the airway, and not be solely focused on treating inflammation or infection of the lymphoid tissues. This goal may not be met in some patients, thus potentially contributing to residual problems seen after surgery. The possibility of further treatment, including collaboration with orthodontists to improve the craniofacial risk factors, should be considered in children with residual problems.     

Association of ibuprofen use with post-tonsillectomy bleeding in older children

Objective

Evaluate post-tonsillectomy outcomes in children discharged with ibuprofen versus those without.

Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea

Objectives

In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DISE)-directed surgical treatment.

Methods

31 consecutive children with OSA following TA underwent DISE. 26 completed DISE-directed operative management of the level(s) of ongoing upper airway obstruction. Pre- and postoperative OSA were assessed through a detailed history (of nighttime symptoms (NS) and daytime symptoms (DS)), physical examination, and polysomnography.

Results

Age ranged 5–18 years (mean 9.7 ± 3.4). Fourteen of 26 had trisomy 21 (51%). Operations were performed in the following frequencies: lingual tonsillectomy (LT) (22), midline posterior glossectomy (MPG) (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2). Overall, 92% reported subjective improvement. NS improved from 5.8 ± 2.9 preoperatively to 2.1 ± 2.5 postoperatively (p < 0.05), while DS improved from 2.1 ± 1.3 preoperatively to 0.6 ± 1.1 postoperatively (p < 0.05). Seventeen patients completed preoperative polysomnography, while only 11 of them also completed postoperative polysomnography. Mean OAHI fell from 7.0 (±5.8) events/hr to 3.6 (±1.8) events/hr (t-test, p = 0.09).

Conclusions

Individualized, multilevel, DISE-directed operative therapy was associated with substantial improvement in subjective measures of sleep.     

Preliminary Findings from Our Experience in Anterior Palatoplasty for the Treatment of Obstructive Sleep Apnea

Objectives

Obstructive sleep apnea (OSA) is a common disorder affecting at least 2% to 4% of adult population characterized by the collapse of the pharyngeal airway. It is well established that retropalatal region is the most common site of obstruction. Consequently, many surgical techniques have been introduced. The purpose of this study is to present our preliminary results in the anterior palatoplasty (AP) compared with results of uvulopalatal flap (UPF).

Methods

Thirty-eight consecutive patients with mild-moderate OSA were prospectively enrolled into a randomised surgical protocol. Surgical success was measured primarily by satisfactory reduction in snoring, as reported by snoring assessment questionnaire (SQ) of sleep partners. Secondary outcomes measures included improvement in the Epworth Sleepiness Scale (ESS) scores, changes in the magnitude of pharyngeal collapse, and postoperative pain intensity.

Results

The ESS after AP improved from a preoperative value 8.5±3.7 to a postoperative mean of 4.9±3.2 (P<0.001) after UPF improved from a preoperative value of 8.1±3.5 to 5.2±3.2 postoperatively (P<0.001). The results of satisfactory reduction in the volume of snoring and response at polysomnographic data were also similar in both procedures. We reported a statistically significant difference of the collapse noted at Müller manoeuvre that improved from 2.7±1.0 on average, to 1.1±0.9 (P<0.001) after AP and with a lesser extent, (from 2.8±1.1 on average to 1.8±1.1; P<0.05), after UPF. The mean duration of pain was 10.8 days for UPF patients and 7.1 days for AP patients. The mean pain score in the first 3 days, was 6.8 in UPF patients and 5.1 in AP patients.

Conclusion

The subjective and objective improvements evidenced may suggest how AP is far superior to other techniques aimed at creating a palatal fibrotic scar. In the light of these results we can suggest AP procedure as more practical and comfortable when compared to UPF.     

OSAS and upper pharynx surgery: Does basilingual collapsus always rhyme with failure?

ObjectiveDrug-induced-sedation endoscopy (DISE) has proved superior to awake clinical examination for diagnosis of upper-airway obstruction sites and surgical planning. Our question is: does multilevel obstruction on DISE systematically entail failure for surgery limited to the upper pharynx?Material & methodsWe conducted a retrospective single-center study in patients with obstructive sleep apnea syndrome (OSAS) treated by single-level surgery of the upper pharynx (tonsillectomy with or without pharyngoplasty). Preoperative assessment included polysomnography (PSG) and DISE. Surgical efficacy was assessed on postoperative PSG. Treatment response was defined by postoperative apnea-hypopnea index (AHI) < 20 events/h with 50% reduction, and cure by AHI < 10 (patients with preoperative AHI ≤ 10 being excluded). Efficacy was compared between groups without (group A) and with basilingual or laryngeal collapsus on DISE (group B).ResultsWe analyzed 63 patients, with mean preoperative AHI 33.8 ± 17.9 events/h. The two groups (A, n = 36; B, n = 27) were clinically comparable. Postoperative PSG took place at a mean 8.5 ± 11.5 months. The success rate was 66.7% in group A (mean reduction in AHI, 57.3 ± 36.2%) and 59.3% in group B (mean reduction, 53.9 ± 39.2%). Cure rates were respectively 48.5% and 48.1%. There was no statistically significant difference between the two groups (P > 0.1).ConclusionsOropharyngeal surgery can alleviate associated obstructive sites found on DISE in the lower pharynx, and step-by-step treatment shows efficacy equal to that of single-step multilevel surgery.     

Sleep Apnea and Down's Syndrome

Objective—Obstructive sleep apnea has been reported to occur in 20–50% of children with Down's syndrome in case series of patients referred for evaluation of suspected sleep apnea. In this population-based controlled study, we aimed to investigate whether sleep apnea is related to Down's syndrome.

Material and Methods—Every child aged 2–10 years with Down's syndrome residing in the Umeå healthcare district (n = 28) was invited to participate in the study, with their siblings acting as controls. Successful overnight sleep apnea recordings and echocardiography were performed in 17/21 children with Down's syndrome and in 21 controls.

Results—Obstructive sleep apnea could not be diagnosed, either in children with Down's syndrome or in the control children. The apnea-hypopnea index in the children with Down's syndrome was 1.2 ± 1.5 and did not differ from that in controls. Snoring and hypertrophy of the tonsils were more common in children with Down's syndrome than in controls. Children with Down's syndrome slept for a shorter time (p < 0.001) and changed body position more often (p < 0.05) than the control children.

Conclusions—Snoring, restless sleep and hypertrophy of the tonsils were common among children with Down's syndrome. Obstructive sleep apnea was, however, not related to Down's syndrome in the present population-based controlled study.     

超声刀在治疗儿童阻塞性睡眠呼吸暂停低通气综合征中的应用

目的 探讨超声刀辅助下手术治疗儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的可行性。方法 将38例入选儿童OSAHS患者分为A、B两组,A组(18例)用超声刀辅助下手术,B组(20例)采用传统方法手术,对术中出血量、手术时间、术后疼痛程度、术后伤口愈合情况及术后出血等几个方面进行对照观察研究。结果 术中出血量、手术时间及术后出血概率超声刀组较传统手术组明显减少,差异有统计学意义。超声刀术组与传统手术组在创面白膜生成及脱落时间、术后切口生长情况及术后疼痛方面差异无统计学意义。结论 超声刀辅助手术治疗儿童OSAHS具有微创、安全及可行性等特点,是一种治疗儿童OSAHS较好的方法。