Paediatric adenotonsillectomy as a daycase for obstructive sleep apnoea: How we do it in a tertiary unit

Background

Paediatric adenotonsillectomy is a common ENT operation. Daycase surgery for uncomplicated, elective procedures is encouraged in order to improve efficiency in healthcare. For patients with obstructive sleep apnoea (OSA), most units advocate an overnight stay for adenotonsillectomy, a procedure usually performed as a daycase in other contexts.

Methods

A retrospective casenote review was carried out from 1st December 2011 to 1st December 2012 for all children undergoing daycase adenotonsillectomy for treatment of OSA at Bart's Children's and the Royal London Hospital.

Results

250 children underwent adenotonsillectomies for OSA as daycase procedures over twelve months. 6% had immediate, unplanned overnight admissions. 3% were readmitted within 30 days. No patients readmitted required surgical intervention.

Conclusion

For an appropriately selected child, adenotonsillectomy can be safely performed as a daycase procedure in a tertiary centre.     

Gastroesophageal reflux as a predictor of complications after adenotonsillectomy in young children

Objective

To examine characteristics of young children with gastroesophageal reflux (GER) who experienced complications within the first 24 h after adenotonsillectomy.

Study design

Subset analysis of a larger retrospective cohort.

Methods

A retrospective chart review was performed at a tertiary care children's hospital. Consecutive records of children 3 years old and younger undergoing adenotonsillectomy (AT) over a 5-year period were reviewed. Children with a clinical history of GER were selected for the study.

Results

993 children were included in the initial analysis, and GER was found to be a significant independent variable predictive of early complications. 81 children with a history of GER were included in this study and 8 (9.9%) were found to have experienced complications within the first 24 h. Six of the complications were airway-related; two required re-intubation within the first 24 h. All 8 children with complications had symptoms of sleep-disordered breathing and two had documented severe obstructive sleep apnea (AHI 18.6 and 27.2). Seven children had other risk factors for complications after AT. Eighteen (22%) children had a prolonged length of stay (range 2–7 days); additional risk factors were present in these patients as well.

Conclusions

Knowledge of risk factors for complications following adenotonsillectomy is critical for identifying at-risk patients that may warrant closer post-operative observation. GER has been previously identified as a risk factor for complications in young children. Upon closer analysis, young children with GER who have other known risk factors may be at a further increased risk for airway complications and prolonged hospitalization. Parents of these children can be counseled on the post-operative risks and the possibility of a longer hospitalization.     

Velopharyngeal dysfunction in children with Prader-Willi syndrome after adenotonsillectomy

Introduction

Prader-Willi syndrome (PWS) is a rare genetic disorder with an incidence rate of 1 in 10,000–30,000. Patients with PWS typically have symptoms related to hypotonia, obesity, and hypothalamic dysfunction. A high rate of obstructive sleep apnea (OSA) is found among this population of patients. Adenotonsillectomy has been advocated as a first line approach for treatment of OSA in patients with PWS. Velopharyngeal dysfunction (VPD) is a known complication of adenotonsillectomy. VPD can also be present in patients with global hypotonia, such as those with PWS. The objective of this study is to review the occurrence of VPD in patients with PWS after adenotonsillectomy for OSA.

Methods

A retrospective review was performed of all patients with PWS and OSA from a tertiary pediatric hospital between the years of 2002 and 2012. Pre- and post-operative sleep studies and sleep disordered breathing symptoms, post-operative VPD assessment by the speech-language pathologist (SLP), and VPD treatments were evaluated.

Results

Eleven patients (five males and six females), fitting the inclusion criteria, were identified. The age of the patient at the initial otolaryngologic evaluation ranged from 2 to 9 years. All patients underwent adenotonsillectomy for sleep disordered breathing. Four patients were diagnosed with post-operative hypernasality after assessment by a speech-language pathologist. The hypernasality ranged from mild to moderately severe. Of the four patients with hypernasality, two were found to have structural issues requiring surgery (pharyngeal flap). Both of the surgical patients experienced significant improvement in their VPD after surgery. The remaining two patients were found to have articulation error patterns that were considered more developmental in nature and both responded to speech therapy. All patients, except one, had improvement in their polysomnogram or sleep symptoms after adenotonsillectomy. However, three patients continue to require continuous positive airway pressure at night.

Conclusion

Velopharyngeal dysfunction may occur after adenotonsillectomy in patients with Prader-Willi Syndrome. Families should be counseled of this risk and the potential need for operative intervention to correct it.     

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management

Objective

Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management.

Methods

Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year.

Results

Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms.

Conclusions

Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.     

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.     

Avoiding airway obstruction after pediatric adenotonsillectomy

Objective

To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea.

Design

Computerized retrospective review of single surgeon case series.

Setting

Tertiary children's medical center.

Methods

Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia.

Results

During the period March 2004-August 2007, 864 children underwent adenotonsillectomy by a single surgeon—604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction—none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis.

Conclusion

Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.     

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

Objective

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

Methods

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

Results

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

Conclusions

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

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.     

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.     

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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.     

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.     

Logistic regression analysis of risk factors for prolonged pulmonary recovery in children from aspirated foreign body

Objective

Foreign body aspiration is a life-threatening emergency for children. Fried chicken is commonly available all over the world, but no cases have previously been reported addressing this food as a tracheobronchial foreign body. We report an extremely rare case of tracheobronchial aspiration of fried chicken complicated by severe bronchitis and postoperative atelectasis. To clarify predisposing factors related to bronchopulmonary complications, we also reviewed paediatric cases of tracheobronchial foreign bodies treated in our department over the past 14 years.

Methods

We retrospectively reviewed a total of 77 cases of tracheobronchial foreign bodies from 1988 to 2011. The main outcome measure was duration of hospitalisation, reflecting postoperative therapy. Logistic regression analyses were conducted to determine risk factors for longer hospitalisation.

Results

Age, sex, and interval between the aspiration episode and bronchoscopy were not significantly associated with longer hospitalisation. Regarding kinds of foreign bodies, higher rates of longer hospitalisation were noted for patients who had aspirated peanut or animal material, as compared to patients who had aspirated non-organic material (odds ratio, 5.80; 95% confidence interval, 1.12–30.43).

Conclusions

In terms of predicting the risk of pulmonary complications, the type of foreign body aspirated offers a more meaningful factor than the interval between aspiration and operation. Specifically, peanuts or animal material containing oils appear to be associated with a more prolonged pulmonary recovery even after retrieval of the foreign body.     

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.     

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.     

Is drain placement necessary in pediatric patients who undergo the Sistrunk procedure?

Background

Thyroglossal duct cysts are usually managed with the Sistrunk procedure, which involves excision of the cervical cyst with the central portion of the hyoid bone, along with its tract. Surgical drains are commonly placed with this procedure, which necessitates postoperative hospital admission.

Objective

The aim of this study is to determine if surgical drain placement is necessary in pediatric patients who underwent the Sistrunk procedure.

Methods

The current study describes the outcomes of 30 consecutive children who underwent the Sistrunk procedure without drain placement. Complication rates are compared to an age-matched control group who had drains placed.

Results

No major complications, including hematomas were observed in the study group; outpatient surgery was safely observed in 20 patients. No significant difference in complication rates was observed between the study and control groups.

Conclusions

Routine drain placement in children who are undergoing the Sistrunk procedure may not be necessary. Subsequently, postoperative admission may be avoided.     

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.     

Vestibular function in children with auditory neuropathy spectrum disorder

Objective

Children with auditory neuropathy spectrum disorder (ANSD) account for about 10% of paediatric patients referred for cochlear implantation. Vestibulopathy may be associated with ANSD, and may have implications when formulating management plans in this patient group. We wanted to determine the incidence and predictive factors for vestibulopathy in this patient group to guide vestibular testing in this patient population, and give insight to the aetiology of ANSD.

Methods

We reviewed the outcomes of vestibular function testing in a cohort of paediatric patients with ANSD.

Results

Probable or definite vestibulopathy was seen in 42% of patients who were tested. Vestibulopathy was associated with medical co-morbidities, but was not associated with imaging findings.

Conclusions

Vestibulopathy is relatively prevalent in this patient group, and should be considered when planning the investigation and management of children with ANSD.     

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.     

Predicting complications after adenotonsillectomy in children 3 years old and younger

Objectives

To identify risk factors for complications in the first 24 h after surgery in the young (<4 years old) adenotonsillectomy patient.

Methods

A retrospective chart review was performed at a tertiary care children's hospital. Consecutive records of all children of age 3 years and younger undergoing adenotonsillectomy over a 5 year period were included in the study. The main outcomes measured were total and airway complications occurring on post-operative days 0-1.

Results

993 patients were included in the study. The mean age was 2.94 years old. Witnessed apneas (74.1%) and snoring (59.2%) were the most frequent pre-operative symptoms. 700 children were admitted with a mean length-of-stay of 1.22 days (0-9 days) and a mean time-to-oral intake of 0.28 days (0-4 days) among those patients admitted. The total number of complications was 102 in 98 patients (9.9%). There were 35 complications on post-operative days (POD) 0-1 (3.5%), and 23 of those were airway-related (2.3%). With regard to all complications on POD 0-1, significant predictors were nasal obstruction, gastroesophageal reflux disease, prematurity and a history of cardiovascular anomalies. Significant predictors of airway complications on POD 0-1 were younger age (1-2 years old), larger adenoid size, nasal obstruction, and a history of cardiovascular anomalies.

Conclusions

Knowing the stated risk factors for complications in the early post-operative period after adenotonsillectomy in the younger pediatric patient can help select certain patients for closer monitoring. Specifically, children aged 1-2 years old with a history of nasal obstruction from large adenoids, gastroesophageal reflux disease, prematurity, and/or cardiovascular anomalies appear to be at higher risk for early complications and should warrant closer observation.