Quality of life after adenotonsillectomy for children with sleep-disordered breathing: A linear mixed model analysis

Objective

To study changes in quality of life (QoL) after adenotonsillectomy (T&A) in children with sleep-disordered breathing (SDB), and to elucidate discrepancies in QoL improvements after T&A in children of different gender, age, adiposity status, and disease severity.

Materials and methods

Children aged 2–18 years were recruited. All children had SDB-related symptoms and underwent preoperative full-night polysomnography (PSG). Caregivers completed the first obstructive sleep apnea 18-items questionnaire (OSA-18) prior to T&A and the second OSA-18 survey within 3 months after surgery. Disease severity was defined as primary snoring (apnea/hypopnea index, AHI < 1), mild obstructive sleep apnea (OSA) (5 > AHI ≥1), and moderate-to-severe OSA (AHI ≥ 5). Discrepancies in OSA-18 score changes after T&A for different groups were assessed using the linear mixed model.

Results

In total, 144 children were enrolled (mean age, 7.0 ± 3.6 years; 76% boy). The OSA-18 total score changes after surgery were not significantly different by gender (boys vs. girls), age group (≥6 years vs. <6 years), or adiposity (obese vs. non-obese). The OSA-18 total score changes after surgery differed by disease severity (primary snoring vs. moderate-to-severe OSA, P = 0.004; mild OSA vs. moderate-to-severe OSA, P = 0.003). Children with moderate-to-severe OSA had greater improvement in OSA-18 total score after surgery than those with mild OSA or primary snoring.

Conclusions

Children with SDB had QoL improvement after T&A, as documented by OSA-18 score changes. The QoL improvement after T&A for SDB children increased as disease severity increased, and the improvement was not affected by gender, age, or adiposity.     

Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy

Objective

The aim of our study was to investigate subclinical cardiac disturbances in patients with symptoms due to adenotonsillar hypertrophy (ATH) and the impact of adenotonsillectomy (AT) using conventional and novel echocardiographic measures.

Material and methods

Thirty patients with grade 3 or 4 ATH (mean age: 7.86 ± 3.83 years; 10 females) and 30 healthy, age- and sex-matched volunteers (mean age, 8 ± 2.77; 14 females) were enrolled in the study. In addition to conventional two-dimensional and Doppler echocardiographic parameters, tissue Doppler parameters, including myocardial performance indices (MPIs) of both the right (RV) and left ventricle (LV), were studied. The severity of obstructive sleep apnea (OSA) was determined using the OSA-18 health quality questionnaire. The OSA-18 questionnaire and echocardiographic examination were repeated after AT in patients with ATH.

Results

The total OSA-18 scores for the control, preoperative, and postoperative groups were 39.56 ± 19.98, 80.63 ± 22.32, and 44.10 ± 20.31, respectively. Conventional parameters were not different among the groups. The mean pulmonary artery pressure estimated using the Mahan formula was increased in the ATH group compared with that in the control group (21.72 ± 4.25 vs. 12.43 ± 3.83, respectively; p < 0.001) and significantly improved after AT (21.72 ± 4.25 vs. 16.09 ± 4.53; p < 0.001). The RV MPI was significantly different between the control and ATH groups (0.322 ± 0.052 vs. 0.383 ± 0.079, respectively; p = 0.001). Both the LV and RV MPI significantly improved (0.515 ± 0.066 vs. 0.434 ± 0.052, p < 0.001; and 0.383 ± 0.079 vs. 0.316 ± 0.058, p = 0.018, respectively) after surgery for ATH.

Conclusions

Our study revealed that the patients with OSA-specific symptoms due to ATH had higher pulmonary artery pressure and impaired RV function according to novel echocardiographic parameters. Surgery for ATH seems to have an important effect on both LV and RV function.     

Comparing postoperative quality of life in children after microdebrider intracapsular tonsillotomy and tonsillectomy

Objective

To evaluate postoperative quality of life in patients undergoing microdebrider intracapsular tonsillotomy and adenoidectomy (PITA) in comparison with traditional adenotonsillectomy (AT) and to assess PITA's efficacy in solving upper-airway obstructive symptoms.

Methods

29 children with adenotonsillar hyperplasia referred for AT were included. Patients were divided into two groups: Group 1 (underwent PITA) included 14 children (age 5.1 ± 1.8 years) affected by night-time airway obstruction without a relevant history of recurrent tonsillitis; Group 2 (underwent AT) included 15 children (age 5.2 ± 1.7 years) with a history of upper-airway obstruction during sleep and recurrent acute tonsillitis. Outcomes measures included the number of administered pain medications, time before returning to a full diet, Obstructive Sleep Apnea survey (OSA-18), parent's postoperative pain measure questionnaire (PPPM) and Wong–Baker Faces Pain Rating Scale (WBFPRS).

Results

Postoperative pain was significantly lower in the PITA group, as demonstrated by PPPM and WBFPRS scores and by a lower number of pain medications used. PITA group also resumed a regular diet earlier (P < 0.001). OSA-18 scores proved that both PITA and AT were equally effective in curing upper-airway obstructive symptoms.

Conclusion

PITA reduces post-tonsil ablation morbidity and can be a valid alternative to AT for treating upper-airway obstruction due to adenotonsillar hyperplasia.     

Questionnaire OSA-18 has poor validity compared to polysomnography in pediatric obstructive sleep apnea

Objective

To evaluate the diagnostic value of the quality-of-life instrument OSA-18 by comparing it with objective data from polysomnography in children with sleep-disordered breathing.

Study Design

Cross-sectional.

Patients and Methods

Full-night polysomnographic data were obtained from 225 subjects, 139 boys and 86 girls, median age 4.5 years (1–12) in our sleep laboratory. Their caregivers answered the OSA-18 quality-of-life instrument (range 18–126). The polysomnographic parameter, the apnea-hypopnea index (AHI) was compared with the total symptom score (TSS) and with the subscale of sleep disturbance (SD) from the OSA-18 questionnaire. Receiver operating characteristic (ROC) curves were created to test the predictive value of OSA-18.

Results

With the TSS of the OSA-18 at ≥60, compared with AHI levels of >1 and ≥5, the sensitivity was 55.2% and 59.3% respectively, and the specificity 40.9% and 48.4%, respectively. With the TSS > 80 and AHI levels of ≥5 and ≥10, the sensitivity was 24.6% and 32.1%, respectively. For the subscale of SD, the majority of the subjects showed poor correlation with the AHI values. The ROC area under the curve for different levels of the AHI (>1, ≥5, and ≥10) was 0.49, 0.57, and 0.56, respectively.

Conclusions

The OSA-18 questionnaire showed poor validity in detecting and predicting pediatric OSA. The majority of the children with severe OSA would not be correctly diagnosed if the OSA-18 were used as a dominant diagnostic tool.     

The impacts of adenotonsillar hypertrophy on periodontal health in children: A prospective controlled pilot study

Objectives

To evaluate the impacts of obstructive adenotonsillar disease on periodontal health and to assess the efficacy of adenotonsillectomy in the prevention of chronic periodontitis in children.

Methods

This prospective and controlled clinical study was conducted between August 2012 and February 2013 with 35 pediatric patients who had permanent anterior dentition. The study group included twenty patients (n = 20) who had complaints of chronic mouth breathing and snoring and were diagnosed with obstructive adenotonsillar disease. These patients underwent adenoidectomy with or without tonsillectomy. We performed periodontal examinations to assess the periodontal health status in these children before and two months after surgery. The periodontal measures included plaque index (PI), pocket depth (PD) and gingival index scores (GI). Subsequently, these periodontal measures were compared with healthy control group who had no adenotonsillar disease (n = 15).

Results

Among the study group six patients underwent adenoidectomy and 14 patients underwent adenoidectomy combined with either tonsillectomy or tonsillotomy. The preoperative PI, PD and GI scores of the study group were 1.27 ± 0.39, 1.34 ± 0.31 and 0.97 ± 0.37 respectively. These scores were significantly higher compared to the control group (p < 0.001). These periodontal index scores were significantly improved after surgery (p = 0.008 for PI and p < 0.001 for both PD and GI). In addition, we found no difference in postoperative values of PD and GI between the study group and control group.

Conclusion

We concluded that obstructive adenotonsillar disease adversely affects periodontal health in children and surgical management of obstruction improves the clinical findings. However, more comprehensive research is required to elucidate the association between adenotonsillar hypertrophy and periodontal disease.     

Surgical duration of cochlear implantation in an academic university-based practice

Objective

Establish the time to safely and efficiently perform cochlear implantation (CI) in a university-based academic center.

Study Design

Case series with chart review.

Setting

Academic neurotologic referral center.

Patients

424 patients who underwent CI surgery between 2002 and 2010.

Intervention

Unilateral, bilateral or revision CI using commercially available devices approved for use in the United States.Main outcome measures: mean surgical duration (SD) and mean total operative room time (TORT).

Results

Overall mean SD for all 424 patients was 83 ± 30 min (min) whereas the mean TORT was 135 ± 56 min. The mean SD for unilateral CI was 84 ± 18 min for the first implant and 82 ± 22 min for the second implant (p = 0.55). The SD for primary and revision CI was 83 ± 18 min and 85 ± 36 min, respectively (p = 0.51). The mean SD for pediatric and adult CI was 83 ± 21 min and 83 ± 18 min, respectively (p = 0.92). The mean SD without resident assistance was 74 ± 14 min whereas with the assistance of a resident the mean SD was 84 ± 20 min (p = 0.02). When ossification was encountered the mean SD was 90 ± 32 min compared to 82 ± 19 min when absent (p < 0.001). An association was found between TORT or SD, and the year of surgery, presence of ossification and the involvement of an assistant.

Conclusion

In a university-based academic center, CI surgery can be safely and efficiently performed, supporting future cost-effectiveness analysis of its current practice.     

Nasal pH in patients with chronic rhinosinusitis before and after endoscopic sinus surgery

Purpose

Physiologically acidic nasal pH depends on intact nasal mucosal function. The aim of this study was to determine nasal pH in patients with chronic rhinosinusitis and to investigate the changes in pH related to mucosal healing after endoscopic sinus surgery.

Materials and methods

Normal subjects and the patients with chronic rhinosinusitis who showed no recurrence after endoscopic sinus surgery were enrolled. Using a portable pH meter and a glass-tipped probe, nasal pH was measured in the inferior meatus in normal subjects and patients before and after surgery at 3 months.

Results

The mean (± SD) nasal pH was 6.5 ± 0.5 (5.9 to 7.3) in 19 normal subjects, and 6.7 ± 0.6 (5.3 to 7.6) in 19 CRS patients before surgery, which showed no significant difference between the groups. The nasal pH values were in the range of 3.8–7.7 (mean ± SD 5.7 ± 0.9) at 3 months after surgery, and significantly lower than the preoperative values in patients (P = .004). The patients showing pH lower than 6.0 accounted for 10.5% before surgery, but 68.4% after surgery.

Conclusions

Normal nasal pH was in the slightly acidic range, and the mean nasal pH of patients with chronic rhinosinusitis fell within normal limits as well, which indicates that chronic rhinosinusitis may not disturb the electrolyte milieu of the nasal mucosa. The average nasal pH measured at 3 months after endoscopic sinus surgery exhibited acidity of pH 5.7. The factors causing a fall in nasal pH during the healing period after the sinus surgery remain to be elucidated.     

YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery

Objectives

Assess the overall quality of information on adenotonsillectomy and ear tube surgery presented on YouTube (www.youtube.com) from the perspective of a parent or patient searching for information on surgery.

Methods

The YouTube website was systematically searched on select dates with a formal search strategy to identify videos pertaining to pediatric adenotonsillectomy and ear tube surgery. Only videos with at least 5 (ear tube surgery) or 10 (adenotonsillectomy) views per day were included. Each video was viewed and scored by two independent scorers. Videos were categorized by goal and scored for video/audio quality, accuracy, comprehensiveness, and procedure-specific content. Study design: Cross-sectional study. Setting: Public domain website.

Results

Fifty-five videos were scored for adenotonsillectomy and forty-seven for ear tube surgery. The most common category was educational (65.3%) followed by testimonial (28.4%), and news program (9.8%). Testimonials were more common for adenotonsillectomy than ear tube surgery (41.8% vs. 12.8%, p = 0.001). Testimonials had a significantly lower mean accuracy (2.23 vs. 2.62, p = 0.02), comprehensiveness (1.71 vs. 2.22, p = 0.007), and TA specific content (0.64 vs. 1.69, p = 0.001) score than educational type videos. Only six videos (5.9%) received high scores in both video/audio quality and accuracy/comprehensiveness of content. There was no significant association between the accuracy and comprehensive score and views, posted “likes”, posted “dislikes”, and likes/dislikes ratio. There was an association between “likes” and mean video quality (Spearman's rho = 0.262, p = 0.008).

Conclusion

Parents/patients searching YouTube for information on pediatric adenotonsillectomy and ear tube surgery will generally encounter low quality information with testimonials being common but of significantly lower quality. Viewer perceived quality (“likes”) did not correlate to formally scored content quality.     

Double-blind placebo-controlled randomized clinical trial on the efficacy of Aerosal in the treatment of sub-obstructive adenotonsillar hypertrophy and related diseases

Background

Adenotonsillar hypertrophy (ATH) is a frequent cause of upper airways obstructive syndromes associated to middle ear and paranasal sinuses disorders, swallowing and voice disorders, sleep quality disorders, and occasionally facial dysmorphisms. ATH treatment is essentially based on a number of medical–surgical aids including nasal irrigation with topical antibiotics and corticosteroids and/or treatment with systemic corticosteroids, immunoregulators, thermal treatments, adenotonsillectomy, etc.

Objectives

The aim of the present study is to assess the efficacy of Aerosal^® halotherapy in the treatment of sub-obstructive adenotonsillar disease and correlated conditions compared to placebo treatment.

Methods

A total of 45 patients with sub-obstructive adenotonsillar hypertrophy were randomized to receive either Aerosal^® halotherapy or placebo for 10 treatment sessions. The main outcome was a reduction greater than or equal to 25% from the baseline of the degree of adenoid and/or tonsillar hypertrophy.

Results

In the intention-to-treat analysis, a reduction of the degree of adenoid and/or tonsillar hypertrophy ≥25% from baseline after 10 therapy sessions was found in 44.4% of the patients in the halotherapy arm and in 22.2% of the patients in the placebo arm (P = 0.204). Among the secondary outcomes, the reduction of hearing loss after 10 treatment sessions in the halotherapy arm was higher than the placebo arm (P = 0.018) as well as the time-dependent analysis showed significantly improved peak pressure in the Aerosal^® group (P = 0.038). No side effects were reported during the trial. In addition, the therapy was well accepted by the young patients who considered it as a time for play rather than a therapy.

Conclusions

Aerosal^® halotherapy can be considered a viable adjunct, albeit not a replacement, to conventional medical treatment of sub-obstructive adenotonsillar syndrome and related conditions. Further research is however needed to improve ATH treatment.     

Prolonged recovery after out-patient pediatric adenotonsillectomy

Objective

To determine variables predictive of recovery room times in pediatric outpatient adenotonsillectomy.

Study design

Retrospective case-control.

Methods

One-hundred ninety consecutive patients undergoing outpatient adenotonsillectomy at an ambulatory surgery center of a tertiary-care free standing pediatric hospital were grouped into upper and lower deciles of recovery room times. Twenty-one variables were analyzed to determine which variables are predictive of prolonged recovery time. Univariate and multivariate analyses were performed.

Results

Of the 190 patients, mean recovery room time was 103 min (SD 53.1), 22 patients were in the lower decile (mean recovery room time of 63 ± 6 min) and 17 patients were in the upper decile (155 ± 40 min, P < 0.0001). Of the 21 variables analyzed, post-anesthesia care unit (PACU) nursing staff was the only significant predictor of prolonged recovery room time. Compared with one PACU nurse, other nurses (N = 5) predicted a longer recovery time (OR = 10.8, 95% CI 2.0-59.5, P = 0.0017). This association remained significant when controlling for anesthesiologist and surgeon (OR = 8.8, 95% CI 1.5-50.9, P = 0.0072). There were no complications in any patients.

Conclusions

Recovery room times after outpatient adenotonsillectomy vary significantly (mean 103 min (SD 53.1), range 50-241 min). Of potential predictors, only the human factor (PACU nursing staff) was associated with prolonged recovery room times, independent of surgeon and anesthesiologist. Development of standardized protocols for nurses to use for discharge has the potential to increase throughput for adenotonsillectomy patients in an outpatient surgery center setting.     

Validation of the Greek OSD-6 quality of life questionnaire in children undergoing polysomnography

Objective

OSD-6 is a disease specific questionnaire for pediatric obstructive sleep apnea (OSA). The aims of this study were to validate OSD-6 in Greek language and correlate OSD-6 with polysomnography results.

Study design

Prospective study.

Setting

Tertiary referral center.

Subjects and methods

OSD-6 questionnaire was translated to Greek and back to English. A prospective study was conducted on children undergoing overnight polysomnography due to snoring and disrupted sleep. Test–retest evaluation was carried out. Internal consistency and test–retest reliability were evaluated. Validity was assessed by exploring correlations between OSD-6 scores and apnea–hypopnea index (AHI), and by comparing total scores of OSA and non-OSA groups. Responsiveness was assessed by comparing preoperative to postoperative total scores in OSA children who underwent adenotonsillectomy.

Results

Test–retest evaluation of 91 subjects showed good internal consistency (Cronbach’s alpha 0.860 for test and 0.873 for retest) and reliability (Pearson’s correlation coefficients between test and retest scores: 0.751–0.546; p < 0.01). Total and domains’ OSD-6 scores and AHI were significantly correlated (Spearman’s correlation coefficients: 0.277–0.630; p < 0.01), while children with OSA had higher total OSD-6 score than those without OSA (median (interquartile range): 16 (11) vs. 10 (7), respectively; p < 0.01), indicating good validity. Postoperative OSD-6 scores were significantly lower than preoperative (2.84 ± 3.21 vs. 15.42 ± 6.48, respectively; p < 0.001), suggesting good responsiveness.

Conclusion

The Greek version of the OSD-6 questionnaire proved to be a valid instrument with satisfactory internal consistency, reliability, validity and responsiveness. Furthermore, in our study OSD-6 was significantly correlated to polysomnography results.     

Do children with adenotonsillar hypertrophy have lower IGF-1 and ghrelin levels than the normal children?

Objectives

We aimed to determine serum IGF-1 levels and plasma ghrelin levels in male children with adenoid and tonsillar hypertrophy and compare with healthy controls.

Methods

Forty-four male children with obstructive adenotonsillar hypertrophy between the ages of 8 and 11.9 years (mean 9.98 ± 0.98 years) and age matched 40 healthy male children (between 8 and 12 years old, mean 9.83 ± 0.85 years) as control group were enrolled in this study. In both the groups plasma ghrelin and serum IGF-1 levels were measured at 08.30, in the morning.

Results

Male children with adenotonsillar hypertrophy had significantly depressed serum IGF-1 levels (227.29 ± 83.11 ng/ml) and plasma ghrelin levels (389.67 ± 170.94 pg/ml) compared to control group (389.67 ± 170.94 ng/ml and 629.76 ± 263.62 pg/ml respectively, p < 0.05). Body mass indexes of children with adenotonsillar hypertrophy were significantly lower than those of their healthy peers (15.72 ± 2.08 kg/m² and 19.12 ± 2.79 kg/m² respectively, p < 0.05).

Conclusions

Delayed growth in male children with adenotonsillar hypertrophy may be related to the lower serum IGF-1 and plasma ghrelin levels compared to that of normal male controls. Since ghrelin increases hunger and food intake and its levels increase before the meals, lower levels lead to decreased appetite and also swallowing difficulties in children with adenotonsillar hypertrophy may lead to suboptimal nutrition. Lower serum levels of IGF-1 in children with adenoid and tonsillar hypertrophy may be secondary to deficient growth hormone stimulation by ghrelin.     

The effect of adenotonsillectomy on right ventricle function and pulmonary artery pressure in children with adenotonsillar hypertrophy

Objectives

Adenotonsillar hypertrophy (ATH) is the most common cause of upper airway obstruction in children. Severe upper airway obstruction may have an effect on chronic alveolar hypoventilation, which consequently may lead to right ventricle (RV) dysfunction induced by hypoxemic pulmonary vasoconstriction. The investigators aimed to study RV function and mean pulmonary artery pressure (mPAP) in patients with ATH who were undergoing adenotonsillectomy by using tissue Doppler echocardiography (TDE).

Methods

The study examined 27 children with ATH who had a mean age of 8 ± 2 years. The subjects were comprised 17 (63%) males and 10 (37%) females. Hypertrophy of the tonsils was graded according to the Brodsky scale. Children having either grade 3 or 4 hypertrophied adenotonsils were recruited for the study. Adenotonsillectomy was performed on all subjects in the study group and echocardiographic examination was repeated 3 months postoperatively.

Results

Tricuspid Em significantly increased after adenotonsillectomy (17.7 ± 3.6 vs. 19.1 ± 5.5, p = 0.04). The RV myocardial performance index (MPI) and mPAP significantly decreased after adenotonsillectomy (RV MPI: 0.57 ± 0.13 vs. 0.40 ± 0.12, p < 0.001 and mPAP (mm Hg): 31 ± 9 vs. 25 ± 7, p = 0.001).

Conclusion

The results of this study, evaluated with the results of previous studies, demonstrated that adenotonsillectomy improved RV performance and reduced mPAP in children with ATH.     

Effectiveness of radiofrequency cryptolysis for the treatment of halitosis due to caseums

Objective

To evaluate the effectiveness of radiofrequency (RF) cryptolysis for caseum-induced halitosis.

Study design

Clinical retrospective study.

Setting

Otorhinolaryngology Head and Neck Surgery Department of Konya Training and Research Hospital in Turkey.

Subjects and methods

Thirty-four patients with caseum-induced halitosis were included. Eight were male (23.5%) and 26 were female (76.5%). Their mean age was 28.29 ± 9.3 (range: 17–48) years. The mean duration of complaint of halitosis before RF cryptolysis was 53.41 ± 42.6 months (range: 6–182 months). The Finkelstein test, organoleptic measurements, and visual analog scale (VAS) were performed before and 12 months after RF cryptolysis.

Results

Before RF cryptolysis, all patients had a positive Finkelstein's test result, organoleptic measurements revealed that three (8.82%) had serious halitosis, 24 (70.58%) had average halitosis, and seven (20.58%) had mild halitosis, and the mean VAS score was 6.82 ± 1.45. The follow-up period after RF cryptolysis was 12 months. After the single RF cryptolysis session, 26 patients (76.47%) were negative for Finkelstein's test, organoleptic assessments revealed that 26 (76.47%), six (17.64%), and two (5.88%) showed complete, partial, and no recovery, respectively, (p < 0.001), and the mean VAS score was significantly better at 1.88 ± 2.5 (p < 0.001). Thirty-two patients (94.1%) exhibited a decrease in VAS score.

Conclusion

RF cryptolysis is a cost-effective, safe, and easily applicable modality for the treatment of halitosis due to caseums in the crypts of the palatine tonsils.     

Prospective, controlled clinical trial of Ankaferd Blood Stopper in children undergoing tonsillectomy

Objectives

This is a prospective study evaluating the efficacy of Ankaferd Blood Stopper as a hemostatic agent compared to hemostasis by means of knot-tie after cold knife dissection tonsillectomy.

Methods

Study design was the use of ABS and the KT to reach hemostasis for patients undergoing tonsillectomy. ABS is applied on right side tonsil fossa and KT is used on left side tonsil fossa. Measured outcomes such as blood loss, surgical time, and complication will be assessed. In total, 47 consecutive patients undergoing cold knife dissection tonsillectomy were studied, in all of whom Ankaferd Blood Stopper wet tampon was used for right side tonsil hemorrhage and knot-tie technique for left side tonsil hemorrhage. Data were collected intraoperatively. Follow-up visits of all patients were completed at postoperative days 1, 3, 7, and 10.

Results

Ankaferd Blood Stopper side had shorter hemostasis time after tonsil removal than knot-tie side (3.19 ± 0.74 min vs 7.29 ± 2.33 min [mean ± SD], p < 0.01) and less blood loss (1.57 ± 2.26 ml vs 14.04 ± 7.23 ml [mean ± SD], p < 0.01). In addition, KT number was less with ABS side as compared to KT side (p < 0.01).

Conclusions

The side on which Ankaferd Blood Stopper was used had statistically significant differences in hemostasis time, blood loss, and knot-tie number in the operation period. Ankaferd Blood Stopper is safe and efficient, and it decreases intraoperative bleeding, reduces operating time, as compared to the traditional hemostasis methods after cold knife dissection tonsillectomy.     

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.     

Do synchronous airway lesions predict treatment failure after adenotonsillectomy in children less than 3 years of age with obstructive sleep apnea?

Objectives

Determine the efficacy of adenotonsillectomy and the role of synchronous airway lesions in treatment failure in children younger than 3 years of age with obstructive sleep apnea.

Methods

A retrospective chart review was conducted for children younger than 3 years of age with obstructive sleep apnea who were evaluated and treated at a tertiary care hospital between 2005 and 2011. All participants underwent adenotonsillectomy or powered-intracapsular tonsillectomy with adenoidectomy and had both pre- and post-operative polysomnograms. Children eligible for airway evaluation underwent flexible laryngoscopy, direct laryngoscopy or bronchoscopy. For analysis, participants were categorized as cured or not-cured with an obstructive apnea–hypopnea index (OAHI) threshold of ≥1.4 indicating residual obstructive sleep apnea.

Results

Thirty-nine children met inclusion criteria and 41% had a post-operative OAHI ≤ 1.4 by polysomnogram. Children failing adenotonsillectomy, (OAHI ≥ 1.4) had a significantly higher pre-operative OAHI (p < 0.001) and lower nadir SpO₂ (p < 0.03) than those considered cured. Thirty-eight percent of the total population underwent airway evaluation, and synchronous airway lesions were identified in 60% of that cohort. None of the children required surgery for their synchronous airway lesions and there was no significant difference between outcome groups in number of patients who underwent airway evaluation or had synchronous airway lesions (p = 1 and p = 0.14, respectively).

Conclusions

Adenotonsillectomy is effective for obstructive sleep apnea in children younger than 3 years of age and the presence of a synchronous airway lesion does not necessarily predict treatment failure.     

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy

Objective

To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy.

Study design

Prospective randomized double blind controlled study.

Methods

Seventy-five children aged 3–10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9–10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24 h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24 h postoperatively).

Results

The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p > 0.05). The mCHEOPS scores at 10 min, 30 min, 1 h, 8 h were significantly lower in both tramadol and ketamine group when compared with control (p < 0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p < 0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p < 0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p > 0.05).

Conclusions

Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.     

Comparison of oxygen desaturation patterns in children and adults with sleep-disordered breathing

Purpose

Although the number of apnea–hypopnea episodes per hour apnea-hypopnea index (AHI) is typically used to evaluate sleep-disordered breathing (SDB) in adults, it does not provide an accurate characterization of SDB in children. We investigated differences in SDB patterns in children and adults to evaluate SDB severity in children.

Materials and methods

Fifteen adults (mean age, 45.3 ± 8.4 years) and 15 children (mean age, 6.7 ± 3.9 years) with adenotonsillar hypertrophy underwent standard polysomnography. The change of oxygen saturation (ΔSpO₂) was defined as the difference between baseline SpO₂ during stable nighttime breathing and the lowest SpO₂ accompanied by an apnea–hypopnea event. The number of apnea-hypopnea episodes was determined using two different criteria to define an episode (criterion 1: cessation of airflow for at least 10 s; criterion 2: cessation of airflow for at least two consecutive breaths).

Results

Mean ΔSpO₂ accompanied by obstructive apneas lasting ≤ 10 s was significantly greater in children than in adults, although there was no significant difference in the duration of apnea–hypopnea episodes. The slope of the regression line between ΔSpO₂ and apnea-hypopnea duration in children was greater than in adults (P < 0.005). AHI in children was higher when calculated using criterion 2 compared to criterion 1 (10.9 ± 9.4 vs. 6.5 ± 4.9/h, P = 0.003).

Conclusions

ΔSpO₂ is a good indicator of SDB severity in children, and should therefore be considered in the diagnosis and treatment of pediatric SDB along with AHI.     

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy

Objectives

Adenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya.

Methods

This was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥25 mm Hg using the Chemla equation. Children with mPAP of ≥25 mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis.

Results

Of the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%–29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR = 3.0 [95% CI 1.08–8.44] p = 0.035) and hyperactivity on history (OR = 0.2 [95% CI 0.07–0.59] p = 0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR = 5.0 [95% CI 1.01–24.37] p = 0.048).

Conclusion

One in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.