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.     

Clinical indicators that predict the presence of moderate to severe obstructive sleep apnea after adenotonsillectomy in children

Objective

To determine if clinical indicators can predict the presence of moderate to severe Obstructive Sleep Apnea (OSA) after Adenotonsillectomy (T&A) in children.

Study Design

Retrospective study.

Setting

Urban Tertiary Care Pediatric Hospital.

Methods

Parents of children (< 18 yrs.) with OSA completed a 55-item questionnaire based on their child’s symptoms at the time of preoperative polysomnography and then again at the follow up polysomnography completed 3 to 6 months after T&A.

Main outcome measures

55 item questionnaire, polysomnography variables.

Results

97 children were included (59 Male and 38 Female). The mean preoperative apnea hypopnea index (AHI) was 30.5 ± 31.6/h and the mean postoperative AHI was 4.4 ± 6.0/h. After T&A, all 97 children had reduction in AHI, and 35 (36.1%) no longer had OSA (AHI < 1/h). The total symptom scores decreased from 15.8 ± 9.4 to 11.3 ± 8.7 after T&A (p < .0001). Fourteen symptoms highly predictive of moderate to severe OSA were identified in the univariate analysis (p < 0.1). Using a cut-point of 4, this 14-item subscale illustrated an overall predictability of 72.2% (73.7% sensitivity and 70.0% specificity) for identifying children with moderate to severe OSA.

Conclusion

A cluster of 14 clinical sleep symptoms are highly predictive of moderate to severe OSA and can serve as clinical predictor for the presence of moderate to severe OSA after T&A.     

Mucopolysaccharidosis: Otolaryngologic findings,obstructive sleep apnea and accumulation of glucosaminoglycans in lymphatic tissue of the upper airway

Objective

The aim of this study is to evaluate otolaryngologic problems (upper airway obstruction, obstructive sleep apnea, restriction of mouth opening, middle ear effusion, hearing and breathing problems) and their treatments on mucopolysaccharidoses (MPS) patients and to investigate accumulation of glucosaminoglycans (GAG) in the upper airway biochemically and pathologically.

Methods

76 MPS patients were evaluated. Forty-two MPS patients underwent polysomnography (PSG) for obstructive sleep apnea (OSA). Pre- and postoperative PSG results of 18 patients were compared. The success and complications of treatments for OSA in MPS were evaluated. Biochemical and histopathological accumulation of GAG in tonsil and adenoid tissue and middle ear effusion were analyzed and compared with the control group.

Results

Forty patients out of 42 tested with PSG had OSA (95%). Adenoid grade, Mallampati grade, restricted mouth opening, rate of difficult intubation were significantly different among MPS subtypes. MPS types III and IV had significantly lower Mallampati scores; type VI had significantly worse mouth opening; and type III had significantly better mouth opening and higher rate of easy intubation when compared to other MPS types. There was no significant difference between MPS subtypes according to tonsil grade, adenoid grade, rate of otitis media with effusion and OSA severity. Statistically significant difference was found between GAG accumulation in adenoid tissue and middle ear effusion of MPS and control group (p < 0.05). However, GAG accumulation in tonsil was not significantly different between MPS and control group. There was a statistically significant improvement in postop Apnea–Hypopnea Index (AHI) compared to preop AHI (p < 0.05).

Conclusions

Most MPS patients have airway obstruction and OSA due to adenotonsillar hypertrophy. Most of these children benefit from adenotonsillectomy, after which OSA significantly improves. They experience high recurrence rate after adenoidectomy; though this is not clinically problematic. They also suffer from conductive hearing loss due to OME, which has to be treated with ventilation tube insertion. However, such operations are usually complicated by difficult endotracheal intubation and restricted mouth opening. Sometimes tracheotomy may be necessary. Tracheotomy is also highly complicated in MPS patients. Significant accumulation of GAG in middle ear fluid and adenoid tissue is present; however, GAG appears not to accumulate in tonsillar tissue.     

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.     

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.     

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.     

Obstructive sleep apnea in younger school children with Down syndrome

Objective

We aimed to assess the prevalence of obstructive sleep apnea (OSA) in 8 year old school children with Down syndrome (DS). While the prevalence in otherwise healthy children is below 5%, the prevalence estimates in children with DS are uncertain (30–80%). OSA directly affects cognitive development and school performance.

Study design

Population based cross sectional study in a limited geographical area.

Methods

Polysomnography (PSG) with video and audio recordings was performed in 8-year-old children with DS in a pediatric sleep unit according to the guidelines of American Academy of Sleep Medicine. Twenty-nine of all 32 children with DS within a restricted area comprising >50% of the Norwegian population and 54% of the children with DS born in Norway in 2002 were enrolled.

Results

This study reports an apnea hypopnea index AHI > 1.5 in 28 of 29 children and an obstructive apnea index (OAI) > 1 in 24 of 29 children. 19 children (66%) had an AHI > 5 and 17 children (59%) had an OAI > 5 which indicated moderate to severe OSA. No correlation was found between OSA and obesity or gender.

Conclusion

The high prevalence of disease found in these previously undiagnosed 8-year-old children underlines the importance of performing OSA diagnostics in children with DS throughout childhood. These findings suggest that the prevalence of OSA remains high up to early school years. In contrast to earlier publications, this current study has the advantage of being population based, the study is performed on children of a narrow age band to estimate prevalence of disease and the diagnostic gold standard of PSG is applied.     

Effects of adeno-tonsillectomy on polysomnography patterns in Down syndrome children with obstructive sleep apnea: A comparative study with children without Down syndrome

Objective

To determine if adeno-tonsillectomy (T&A) in children with Down syndrome (DS) improves breathing, measured by apnea hypopnea index (AHI), rapid eye movement AHI (REM-AHI) and the lowest oxygen desaturation (SaO₂), and sleep disruption, measured by arousal index (ArI) and time spent in stages 1-4 and rapid eye movement (REM) sleep and compare these results with a group of non-DS children with obstructive sleep apnea (OSA).

Study design

Retrospective chart review at pediatric sleep center.

Patients

Eleven DS and nine non-DS children underwent pre- and post-T&A polysomnography between 1997 and 2005.

Outcome measures

Pre- and post-T&A polysomnography parameters were compared using paired t-test and independent samples test.

Results

Mean age in DS group was 101 months and non-DS group was 80 months (64% males in DS and 88% in non-DS group). The average BMI was 29.8 and 27.6 for DS and non-DS group. The total AHI showed significant improvement after T&A but this was not as marked as the non-DS group. REM-AHI and lowest SaO₂ did not show significant change in the DS children. The non-DS group showed significant improvement in all respiratory parameters. Both groups showed mild improvement in sleep parameters. With the modest overall improvement, 27% of the DS children required no further treatment. However, 73% required CPAP, BiPAP or oxygen for persistent OSA.

Conclusion

This study supports the fact that T&A in DS children improves some parameters of OSA, however not as markedly as in non-DS children.     

Sleep related quality of life before and after adenotonsillar surgery in pediatric population

Objective

To assess the quality of life in children with adenotonsillar problems before and after adenotonsillectomy in short term follow-up.

Methods

Quasi-experimental study (before and after study) of children with adenotonsillar problems at Tehran University of Medical Sciences, Amir’Alam hospital. Eighty six pediatric patients aged 3 through 13 years (58 boys and 28 girls) who underwent adenotonsillectomy, for treatment of sleep disordered breathing or recurrent throat infection, were recruited. Parents completed OSA-18 quality of life survey and Brouillette score questionnaire before and one month after surgery.

Results

Reliability of the Brouillette score and OSA-18 survey was established by evaluating the Cronbach α value. Cronbach α for Brouillette score was 0.70 and for OSA-18 survey it was 0.88. Preoperative values for the OSA-18 total and domain scores were high in children: mean ± SD; 61.65 ± 20.78. Preoperative values for the Brouillette score were: mean ± SD; 0.41 ± 2.34. The total OSA-18 survey score and the scores for all domains showed significant improvement after surgery: mean ± SD; 28.01 ± 9.09 (P < 0.001). Post-operative Brouillette score had a significant improvement: mean ± SD; −3.57 ± 0.91 (P < 0.001).

Conclusion

Considering the OSA-18 survey and Brouillete score results, surgical therapy with adenotonsillectomy is associated with marked improvement in quality of life in both obstructive and infective adenotonsillar disease.     

Metabolic alterations in children with obstructive sleep apnea

Importance

The incidence of obesity is rising in the United States and has been linked to Obstructive Sleep Apnea (OSA) even in young children. Understanding the role that obesity and OSA play in alterations in metabolic variables that can lead to serious health issues is essential to the care and counseling of affected children.

Objectives

To evaluate the association of alterations in metabolic variables, including insulin resistance, to OSA in young, obese children.

Design

Retrospective, case-control series.

Setting

Tertiary care children's hospital.

Participants

Obese children aged 2-12 years who had undergone overnight polysomography and routine laboratory testing for lipid levels, fasting glucose, and insulin from January 1, 2006 to December 31, 2012 were identified from a TransMed Bio-Integration Suite and Epic's clarity database search.

Results

A total of 76 patients were included for analysis. Forty-three (56.6%) were male, and the mean age was 8.3 ± 2.5 years (range, 2.4–11.9 years). The mean body mass index (BMI) z score was 2.8 ± 0.75 (range, 1.7–6.3), and all patients were obese (BMI z score > 95th percentile). Twenty two patients (28.9%) had an apnea–hypopnea index (AHI) <1/h (no OSA), 27 (35.5%) an AHI≥1 < 5/h, 12 (15.8%) had an AHI ≥5 < 9.99/h, and 15 (19.7%) had an AHI≥10/h. There was no significant difference in total cholesterol, triglycerides, high and low density lipoprotein levels, systolic and diastolic blood pressure in those patients with or without OSA. Fasting insulin, blood glucose, and homeostasis model assessment (HOMA) were significantly higher in patients with OSA compared to those with no OSA (p < 0.01). AHI correlated to alterations in insulin as well as glucose homeostasis on multivariate analysis. Results from logistic regression analysis showed that fasting insulin (p < 0.01), and HOMA (p < 0.01) predicted severe OSA independent of age, gender, and BMI z score in these patients.

Conclusion

Metabolic alterations in glucose and insulin levels, known to be associated with obesity and increased risk for cardiovascular disease, appear to relate to the severity of OSA in young children.     

Validation of a pediatric obstructive sleep apnea screening tool

Objective

Pediatric obstructive sleep apnea (OSA) is a prevalent but under-diagnosed disease. The importance of screening for OSA in every child has been recently re-emphasized by the American Academy of Pediatrics Guidelines. Although several screening questionnaires are available for pediatric OSA, they are either complicated to use or not sensitive enough, and therefore OSA is seldom screened in primary care settings. Here, we validated a previously developed short (6-item) hierarchically-based screening questionnaire tool for pediatric OSA.

Methods

Parents of 85 children referred for a sleep study at a pediatric community-based sleep clinic completed the questionnaire and their children underwent an overnight PSG. Receiver operator curve analyses and other predictive scales were assessed.

Results

The 6-item questionnaire exhibited favorable sensitivity and fair specificity for diagnosis of OSA, which varied depending on the apnea–hypopnea index used for OSA definition.

Conclusions

A 6-item questionnaire is a sensitive and easy-to-use screening tool for pediatric OSA in a pediatric sleep clinic setting.     

Changes in IGF-I, IGFBP-3 and ghrelin levels after adenotonsillectomy in children with sleep disordered breathing

Objective

The aim of this study was to determine the changes in insulin-like growth factor-I (IGF-I), insulin-like growth factor binding protein-3 (IGFBP-3) and ghrelin levels following adenotonsillectomy (T&A) in children with sleep disordered breathing (SDB).

Methods

Forty children (mean age 4.85 ± 2.15 years) clinically diagnosed with adenotonsillar hypertrophy (ATH) related SDB were enrolled. All children underwent T&A. Serum levels of IGF-I, IGFBP-3 and ghrelin were measured before and 6 months after T&A.

Results

Serum levels of IGF-I and IGFBP-3 were significantly higher after T&A (p < 0.001). Serum ghrelin levels showed a significant decrease after T&A (p < 0.001).

Conclusion

Children with ATH related SDB who underwent T&A showed significant increases in IGF-I and IGFBP-3 levels indicating an increase in diurnal growth hormone secretion as well as a significant decrese in ghrelin levels indicating an increased oral food intake in the postoperative period.     

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.     

Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis

Objective

To address the controversy over whether olfactory function is improved or not after endoscopic sinus surgery (ESS) in patients with eosinophilic (ECRS) and non-eosinophilic chronic rhinosinusitis (non-ECRS).

Methods

Between June 2006 and March 2012, 89 adult patients with CRS underwent ESS at Hyogo College of Medicine. There were 55 men and 34 women with a mean age of 53 years old, ranging from 23 to 79 years. The average follow-up period was 10.7 months (3–24) after ESS. Peripheral blood examination, sinonasal CT imaging, and four kinds of olfaction tests [self-administered olfaction test (SAOQ), visual analog scale (VAS), T&T recognition threshold tests (T&T) and intravenous olfaction test using prosultiamine] were performed. We diagnosed ECRS when (i) symptoms of nasal congestion and olfactory disorder, (ii) bilateral chronic rhinosinusitis with nasal polyps (CRSwNPs), (iii) peripheral blood eosinophilia (>7.0%), and (iv) ethmoid sinus dominant opacification in preoperative CT findings (i.e. ethmoid sinuses (E) were more bilaterally occupied than those of maxillary sinuses (M), E/M ≥ 1), were completely fulfilled. We divided the patients into two groups of ECRS (group A) and non-ECRS (group B). Olfaction tests before operation, and at the 3rd, 6th, 12th, and 24th month postoperation were analyzed. The severity and therapeutic evaluation of olfaction were based on criteria of T&T recognition thresholds.

Results

The mean SAOQ and VAS scores showed significant improvement within 6 months after ESS in both group A and group B. In total, the improvement rates were 52.0% (26/50) at 3 months, 58.5% (24/41) at 6 months, 40.5% (15/37) at 12 months, and 41.2% (7/17) at 24 months. The significant improvement of T&T recognition thresholds in group B was maintained for 24 months, whereas those in group A, showing transient improvement, deteriorated after 12 months or more. A significant difference in postoperative T&T recognition between groups A and B was found at the 12th postoperative month. In both A and B, 84% of patients had a response to prosultiamine (positive group) in the preoperative stage. T&T thresholds in the positive group were significantly better that those in the negative groups in the postoperative stage.

Conclusion

Olfactory disorders due to ECRS showed transient improvement that deteriorated as time passed after surgery. The olfaction in the non-ECRS patients recovered comparatively well. Postoperative olfactory results were unfavorable in patients without a preoperative reaction to prosultiamine.     

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.     

Routine post-operative intensive care is not necessary for children with obstructive sleep apnea at high risk after adenotonsillectomy

Objectives

Post-operative respiratory adverse events (AE) are frequent in children having adenotonsillectomy (AT) for obstructive sleep apnea (OSA). Many hospitals have a policy of routine admission to the intensive care unit (ICU) after surgery for children at highest risk. We aimed to determine the frequency and severity of post-operative AE in children admitted to ICU, to assess the appropriateness of this care plan.

Methods

A retrospective chart review was carried out all children admitted to the pediatric intensive care unit after AT for OSA from January 2007 to December 2009. AE were classified as mild, including requirement for supplemental O₂ or repositioning to improve airway or severe, including bag and mask ventilation, CPAP, re-intubation, placement of oropharyngeal airway or unplanned ICU admission for airway compromise.

Results

72 children were identified (21 female, median age 2.8 years). There were 29 AE in 26 patients (36%), including 23 (31.9%) who suffered a mild AE and 6 (8.3%) who had a severe AE. Age, sex, the presence of co-morbidity or the presence of severe OSA did not predict severe AE in this group. Median time to first AE was 165 min. Four of the six severe AE occurred in the post-anesthetic care unit (PACU). There were 60 children who did not have an AE in PACU, of whom 59 did not have a severe AE in the post-operative period, giving a negative predictive value for no worse than a mild AE following an uncomplicated course in PACU of 98.3%.

Conclusions

Our data confirm high rates of AE after AT for high risk patients, however, only 8% suffered a severe AE truly necessitating care in ICU. This outcome was very unlikely if an AE did not occur in PACU. We therefore conclude that routine post-operative ICU care for high risk children may be avoided if prolonged monitoring in the PACU is possible, with admission to ICU reserved for high-risk children with an early AE.     

Ambulatory tonsillectomy for children with severe obstructive sleep apnea without risk factors

ObjectivesRecommendations for polysomnography (PSG) in pediatric sleep disordered breathing (SDB) vary between the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Academy of Pediatrics (AAP). We determined the rates of preoperative PSG in children without risk factors outlined in the AAO-HNS Clinical Practice Guidelines and described the postoperative course of those patients following T&A.MethodsPatients aged 3–17 undergoing T&A for SDB or OSA who did not have an indication for preoperative PSG were included. We conducted retrospective review to describe the rate, type, and timing of respiratory complications for patients with and without PSG following T&A, and discuss cases where disposition was changed due to PSG results.Results1135 patients without risk factors underwent T&A for SDB or OSA. 196 (17%) had a preoperative PSG, of whom 85 (43.3%) had AHI >10 and 38 (24.8%) had an O₂ nadir <80%. 69 (85%) patients with PSG-diagnosed severe OSA were admitted overnight. Of the entire cohort, 5 patients (0.44%) had hypoxemia requiring blow-by oxygen or repositioning. 4 (0.43%) patients without PSG experienced respiratory events and were converted to overnight stay. The timing of respiratory events for all children ranged from immediately following extubation in the operating room to 3 h postoperatively.ConclusionPSG in children without risk factors results in admission of otherwise healthy patients following T&A who would have otherwise undergone ambulatory surgery. PSG alone in pediatric patients with no AAO-HNS risk factors should not influence postoperative disposition. These patients should be monitored for 3 h post-T&A and discharged in the absence of complications.Evidence level2b     

National UK survey on the assessment and surgical management of suspected paediatric obstructive sleep apnoea syndrome

Background

Controversy exists amongst ENT surgeons as to the best way to manage a non-syndromal and otherwise healthy child with suspected OSAS. In 2002, The American Association of Paediatricians stated that the gold standard is a full polysomnography (PSG) for all children with suspected OSA and the revised version in 2012 repeated that requirement but recognized that facilities are not always available. In 2009 a UK Multidisciplinary Consensus Statement disagreed and reserved a full PSG for younger and syndromal or complicated children.We undertook a survey of UK ENT surgeons before and after the UK Consensus Statement to identify common practice with regards to diagnosis and management of suspected paediatric obstructive sleep apnoea syndrome in the UK.

Method

A questionnaire based on the management of a typical clinical case was sent to 542 ENT consultants in 2005 and repeated in 2011.

Results

Less than 2% used PSG in assessing the child presented in our case study in both surveys. About 70% of respondents indicated that they would proceed with management of the child with no form of sleep study at all and this clinical practice has not changed after UK Multidisciplinary Consensus Statement. The majority would treat a child with possible OSAS and no co-morbidities with adenotonsillectomy as an inpatient.

Discussion

The availability of paediatric PSG is very limited and because of a lack of normative data, uncertainty about interpretation of abnormal results, the recognition that even moderate snoring without sleep apnoea has detrimental neuro-cognitive effects and the fact that adenotonsillectomy is a very effective treatment for paediatric OSA we felt that a pragmatic and safe approach was to treat selected patients as if they had a positive PSG with appropriate anaesthetic technique and post operative care and monitoring.     

A systematic review and meta-analysis of cohort studies of echocardiographic findings in OSA children after adenotonsilectomy

Context

There is evidence that OSA in children can be associated with acute and chronic effects on the cardiovascular system due to repetitive episodes of apnea and hypoxemia.

Objective

To assess whether there is an association between OSA and echocardiographic findings in children and whether that association persists after adenotonsillectomy.

Data sources

A literature search was conducted based on PUBMED, EMBASE and LILACS.

Study selection

Children with OSA and children who did not have OSA, who were aged ≤12 years.

Data extraction

Two reviewers extracted data independently; the risk of bias was assessed by examining the selected sample, the recruitment method, completeness of follow up, and blinding.

Results

Seven studies met all the inclusion criteria and methodological requirements. There was a significant difference with elevated mean pulmonary arterial pressure levels in OSA participants compared to those without OSA at preoperative assessment [mean difference (MD) 8.67; confidential interval (CI) 95% 6.09, 11.25]. OSA participants showed a statistically significant increased interventricular septum (IVS) thickness (mm) [MD 0.60; CI 95% 0.09, 1.11]; and right ventricular (RV) dimension (cm/m) [MD 0.19; CI 95% 0.10, 0.28]. There was also a significant increase in right ventricular (RV) dimension (cm/m) [MD 0.10; CI 95% 0.05, 0.14] in OSA children.

Conclusion

There is moderate quality evidence regarding possible association between OSA and right heart repercussions. More prognosis studies are needed, to allow the combination of results in a meta-analysis.     

Prospective quality of life assessment in congenital laryngomalacia

Purpose of study

Disturbances in breathing or feeding may profoundly affect parental perceptions of a newborn's health. Previous research into quality of life for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the quality of life of families of infants with laryngomalacia and the impact of surgical and non-surgical treatments.

Design and method

Pilot prospective analysis using the laryngomalacia quality of life (QOL) survey in families of infants with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (1 never to 5 always).

Results

Twenty-six families were enrolled in the study. Eleven patients were managed medically and fifteen underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error, SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance (ANOVA) and post hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (p < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (p < 0.01). No statistically significant difference was noted between patient groups post-treatment (p > 0.05).

Conclusions

Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.