Adenotonsillar Hyperplasia Research Articles

Tranexamic acid in adenotonsillectomy in children: A double-blind randomized clinical trial

ObjectivesAdenotonsillectomy is one of the most common surgical procedures in pediatric otolaryngology, in which bleeding is a potential complication. We evaluated the efficacy of intravenous tranexamic acid in reducing intraoperative bleeding volume, and bleeding in the following 10 postoperative days in children who underwent adenotonsillectomy. DesignDouble-blind, randomized placebo-controlled trial. SettingTertiary hospital. PatientsNinety-five children of both sexes between four and twelve years old who underwent adenotonsillectomy due to adenotonsillar hyperplasia. InterventionsIntravenous tranexamic acid in the preoperative and at the eighth and the sixteenth hours of the postoperative periods. Main outcome measureBleeding volume was measured in milliliters (mL) at the end of the procedure, and bleeding events were registered in the following 10 postoperative days. ResultsThere was no statistically significant reduction in bleeding volume with the use of tranexamic acid (mean±standard deviation, 135.13±71.44 [tranexamic acid] versus 158.21±88.09 [placebo]; P=0.195). No difference was observed in the incidence of postoperative bleeding in the 10 postoperative days, but the sample size is insufficient to exclude a type 2 error. ConclusionsThere is no benefit in the use of tranexamic acid for reducing bleeding during the transoperative period of adenotonsillectomy in children. More studies with a greater sample are required to evaluate the benefit of tranexamic acid in postoperative bleeding.

Kindliches OSAS und Seromukotympanon

Adenotonsillar hyperplasia is considered as a possible cause for two frequent ENT disorders in children: pediatric obstructive sleep apnea syndrome (OSAS) and otitis media with effusion (OME). The present study analyzes whether a link between pediatric OSAS and OME can also be presumed. Polysomnographic data of 186 children with suspected OSAS were correlated to middle ear ventilation assessed by tympanometry. Tympanograms were classified according to Jerger. In a Kruskal Wallis test, children with an apnea-hypopnea index < 1 (exclusion of OSA by tight criteria), 1-5 or > 5 (definitively pathological value) did not statistically significantly differ in the prevalence of normally ventilated ears and OME. Accordingly, the Mann-WhitneyU test showed that children with normally ventilated ears did not have a statistically different apnea-hypopnea, apnea, hypopnea or snoring index or varying minimal oxygen saturation to children suffering from OME. In the present study, no link was detected between pediatric OSAS and OME.

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

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

Tonsillectomy in children under 4 years of age: Safety and indications

Background: Tonsillectomy with or without adenoidectomy is a worldwide famous pediatric surgery performed by otorhinolaryngologists. This study was designed to review the records of carefully selected children under 4 years of age who underwent tonsillectomy with or without adenoidectomy over a period of 5 years. We studied the safety and indications for tonsillectomy.Design and Setting: A retrospective study was conducted in King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia.Subjects & Methods: The study included 51 children (29 male & 22 female), under 4 years of age (ranged from 12 to 48 months) who underwent tonsillectomy with or without adenoidectomy in between 1989 and 1993 in the Otorhinolaryngology Department, King Abdulaziz University Hospital. Safety and indications for tonsillectomy were also recorded. Myringotomy with or without ventilation tube insertion was performed in cases of otitis media with hearing loss and tonsillitis.Results: Through 1989-1993, the overall number of tonsillectomy with or without adenoidectomy, performed in the Otorhinolaryngology Department, King Abdulaziz Uuniversity Hospital, was 1159. Of the 1159, only 51 (4.4%) were under 4 years of age, ranged from 12 to 48 months. 1108 (95.6%) of total were over 4 years of age. Indications for tonsillectomy under 4 years of age were recorded and were as the following: Recurrent tonsillitis in 24 children (47.05%). Upper airway obstruction due to adenotonsillar hyperplasia causing nasal obstruction and mouth breathing in 16 children (31.37%), Recuurrent otitis media with hearing loss and tonsillitis in 6 children (11.76%), Tonsillar mass in 4 children (7.84%) and Ventricular septal defect in 1 child only (1.6%). The postoperative follow up of these 51 children was uneventful and all children were discharged in the next day of surgery.Conclusion: The results of this study show that tonsillectomy under the age of four is a safe procedure, provided that the patient is carefully selected, using expert anaesthesia on an in-patient basis with close post-operative monitoring. We recommend conducting a recent similar retrospective study to see if there is epidemiologic change in trend of indications for tonsillectomy in our saudi pediatric community.

Tratamiento quirúrgico en los trastornos respiratorios del sueño en los niños

The surgical treatment of sleep-related breathing disorders in children depends on the cause of the upper airway obstruction, which can be located in the nasal fossae, pharynx (the most frequent adenotonsillar hyperplasia), or larynx (laryngomalacia, cysts…), or can be multilevel, as in syndromic diseases. Adenotonsillectomy is the most frequently performed and effective (70–80%) procedure. The aim of this technique is to normalize nocturnal respiratory parameters and daytime symptoms, as well as to revert, or at least to halt, cardiovascular complications, neurocognitive disturbances, growth delay and enuresis, which can develop if treatment is not provided or is delayed. However, despite its effectiveness, adenotonsillectomy more frequently leads to complications in children with sleep apnea-hypopnea syndrome (SAHS) than in those undergoing this procedure for other reasons. Moreover, 20–30% of children with SAHS who undergo adenotonsillectomy will show residual SAHS, and this percentage can increase to 70% in patients with severe SAHS, Down syndrome, craniofacial anomalies, neuromuscular disturbances, and morbid obesity. Consequently, both clinical and polysomnographic follow-up are recommended after adenotonsillectomy, especially in the latter risk group. Finally, other obstructive disorders of the upper airway must also be treated, although less frequently due to their lower incidence. These disorders include choanal atresia or stenosis, laryngomalacia, and hypoplasia of the midface or mandible. Tracheotomy will sometimes be required.

Why do palatine tonsils grow back after partial tonsillectomy in children?

Within the last decade, adenoidectomy with partial tonsillectomy has been revived in children with obstructive sleep-disordered breathing caused by adenotonsillar hyperplasia, generating debate about remaining tonsillar tissue regrowth. The study examined potential risk factors of the regrowth. Prospective, nonrandomised, case series feasibility study of children meeting the criteria for palatine tonsils regrowth after partial tonsillectomy performed in patients with obstructive sleep-related breathing disorder was carried out. Out of 793 operated children, 294 after adenoidectomy and 373 after adenotonsillotomy were followed up for 4 years in 12-month intervals. In 27 children after adenotonsillotomy, regrowth of tonsillar tissue was observed. In 22 individuals after adenoidectomy alone, hyperplasia of palatine tonsils was noted. The children had bacterial cultures of pharyngeal smears and blood samples tested for anti-streptolysin O, C-reactive protein and total IgE. Caregivers completed a questionnaire reporting on: their child's breathing after surgery; frequency, severity and treatment of upper respiratory tract infections; diet; family history of adenoidal and/or tonsillar hyperplasia; and history of allergy. As controls, 272 participants after adenoidectomy alone and 346 after adenotonsillotomy were examined. The amount of sugar in the diet and the incidence of upper respiratory tract infections after surgery differed between the groups of patients and controls. Other differences were insignificant. The tonsillar tissue remaining after partial tonsillectomy in children has a remarkable tendency to grow back, related to a diet abundant in sugar and numerous upper respiratory tract infections. Tonsillar regrowth was age related and occurred most frequently in individuals older than 7 years.

Indications for tonsillectomy and adenoidectomy.

To review recent clinical trials that provide a foundation on which clinicians can base decisions regarding adenotonsillar surgery for their patients. Review. An evidence-based approach was used to review recent clinical trials addressing indications for adenotonsillectomy, tonsillectomy, and adenoidectomy. Absolute indications for tonsillectomy and adenoidectomy include adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive, or abnormal dentofacial growth; suspicion of malignant disease; and (for tonsillectomy) hemorrhagic tonsillitis. Relative indications for both procedures are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, or speech impairment, and halitosis. Otitis media and recurrent or chronic rhinosinusitis or adenoiditis are relative indications for adenoidectomy but not tonsillectomy. Recurrent or chronic pharyngotonsillitis, peritonsillar abscess, and streptococcal carriage are relative indications for tonsillectomy but not adenoidectomy. Good clinical evidence regarding indications for tonsillectomy and adenoidectomy is available. Clinicians should make recommendations for surgery on the basis of this evidence.

Long term results in the life quality of children with obstructive sleep disorders

SummaryObstructive Sleep Disorders (OSD) affect mostly the pediatric population. Within this group, its main etiology is adenotonsillar hyperplasia, being adenoidectomy or adenotonsillectomy the best treatment option for quality of life improvement.AimTo asses quality of life of children with OSD after adenoidectomy/adenotonsillectomy.MethodA prospective study was carried out with 48 children, between 2 and 11 years, with clinical manifestations of OSD and obstructive adenotonsillar hyperplasia. The OSA18 questionnaire was answered by the parents to evaluate their children’s quality of life before surgery; at about thirty days and at least eleven months after the procedure. A higher score meant a worse quality of life.ResultsBefore surgery, the average OSA18 score was 82.83(SD=12.57), with an average global score for quality of life of 6.04(SD=1.66). Within thirty days after surgery, the average OSA18 score was 34.3 (SD=9.95) with an average global score of 9.6(SD=0.81), both showing significant reduction (p< 0.001). Thirty-four children (70.83%) were re-evaluated between 11 and 30 months (average=16.85; SD=5.16). The average OSA18 score was 35.44 (SD=19.95) with an average global score of 9.28 (SD=1.78). The postoperative evaluations weren’t significantly different.Conclusionsurgery improves the quality of life of children with OSD, and such improvement maintains for the long run.

Low dose radiotherapy for adenotonsillar lymphoid hyperplasia in HIV-positive patients

Lymphoid hyperplasia is common in HIV positive patients. The aim of this study was to determine the response to radiotherapy. Thirty-three adult patients with recurrent tonsillitis or upper airway obstruction due to tonsillar hyperplasia and conformed histology of follicular hyperplasia were included. Thirteen underwent a 24 Gy course of radiotherapy and were followed up for a minimum of 16 weeks post-radiotherapy. There was a statistically significant decrease in the median tonsillar size (95% confidence interval [-3;-2]) and in the median CD4 count (95% CI [3;152]) after 16 weeks. None of the patients had acute tonsillitis or airway obstruction after radiotherapy. Low dose radiotherapy is effective in the management of adenotonsillar hyperplasia in HIV positive patients.

Extra-esophageal acid reflux induced adenotonsillar hyperplasia: Case report and literature review

The etiology of adenotonsillar hyperplasia is not well understood. A 3-year-old child presented with obstructive sleep apnea believed to be secondary to enlarged tonsils and adenoids. Subglottic stenosis was encountered during intubation; the adenotonsillectomy was cancelled. Severe extra-esophageal reflux was identified and treated. At follow-up endoscopy 3 weeks later, the tonsils and adenoids were no longer enlarged or obstructing the airway. The role of extra-esophageal reflux in the pathogenesis adenotonsillar hyperplasia is discussed.

Resolution of Diurnal Incontinence and Nocturnal Enuresis After Adenotonsillectomy in Children

Adenotonsillar hyperplasia causes upper airway obstruction, leading to obstructive sleep apnea. We reviewed the incidence of nocturnal enuresis in a population of children with adenotonsillar hyperplasia. In addition, we investigated the rate of resolution or improvement in enuresis following surgery for relief of adenotonsillar hyperplasia. We studied 86 consecutive prepubertal children, 46 boys and 40 girls, who underwent adenotonsillectomy. Severity of adenotonsillar obstruction was graded on a scale of 1 to 4. A questionnaire regarding voiding problems, including nocturnal enuresis, voids per day and daytime enuresis episodes, was filled out preoperatively and postoperatively by the patients and their parents. Among the 86 patients who underwent adenotonsillectomy 36 (42%) had nocturnal enuresis. In patients with nocturnal enuresis the number of episodes was significantly less after adenotonsillectomy. Overall, 12 patients (33%) had complete resolution, 11 (31%) had significant improvement and 13 (36%) showed no change. In addition, we noted a significant decrease in daytime enuresis episodes and voids per day. Children with upper airway obstruction have a high rate of nocturnal enuresis that improves at twice the anticipated rate after treatment of the airway obstruction. In addition, we observed that daytime voiding dysfunction improves in these patients.

A obstrução nasal e o diagnóstico ortodôntico

OBJETIVO: analisar a freqüência de obstrução nasal em pacientes submetidos a tratamento ortodôntico e verificar a correlação com achados faciais e problemas dentários. METODOLOGIA: oitenta pacientes de 7 a 23 anos (37M; 43F) atendidos no Curso de Especialização da SPO, escolhidos aleatoriamente, foram submetidos à avaliação otorrinolaringológica. RESULTADOS: observou-se incidência de 51,3 % de obstrução nasal. A principal causa do distúrbio respiratório foi a rinite inflamatória, provavelmente alérgica, sendo que cerda de 61% dos casos estavam associados à hiperplasia adenoamigdaliana. Observou-se uma maior freqüência de dolicofaciais dentre os pacientes com obstrução nasal, sem significância estatística. Houve uma associação significante entre a atresia maxilar e mordida cruzada e a presença de palato ogival. CONCLUSÃO: o diagnóstico da obstrução nasal é fundamental nos pacientes com más oclusões, principalmente os dolicofaciais. O tratamento da obstrução nasal deve ser precoce, durante a fase de crescimento e, em geral, conjunto ao ortodôntico.

Pulmonary hypertension due to recurrent juvenile laryngeal papillomatosis

Although pulmonary hypertension secondary to upper airway obstruction caused by adenotonsillar hyperplasia has been well described, the association between laryngeal papillomatosis and pulmonary hypertension has not previously been documented. We report three patients with pulmonary hypertension due to upper airway obstruction caused by laryngeal papillomatosis. Pulmonary hypertension can contribute to significant preoperative and postoperative morbidity and cause intraoperative complications. Preoperative diagnosis and treatment of pulmonary hypertension is therefore essential in these patients.

Die Lasertonsillotomie bei der obstruktiven Schlafapnoe aufgrund adenotonsillärer Hyperplasie im Kindesalter - Ergebnisse aus der Praxis

The adenotonsillar hyperplasia is the most relevant cause for the obstructive sleep apnea in children. Since several years laser-assisted tonsillotomy becomes more common as an alternative treatment especially in children having no tonsillitis history. The therapeutical effect of laser-assisted tonsillotomy in combination with the traditional adenotomy treating the obstructive sleep apnea in children has not yet been researched. In addition literature indicates less pain and fast recovery of the children compared to conventional tonsillectomy. Starting May 2000 until May 2004 laser-assisted tonsillotomy and adenotomy have been performed in 50 outpatient children, mean age of 5.3 +/- 1.7 years, with adenotonsillar hyperplasia and possible sleep apnea. Postoperatively the parents of the patients were questioned with an anonymous questionnaire. Pre- and postoperative symptoms and Brouillette score, the degree of pain and the post-surgical time of recovery have been investigated. 36 questionnaires have been evaluated. The follow-up time was between 4 weeks and 4 years (mean = 1.3 years). With regard to the symptoms snoring, difficulty breathing during sleep and apnea 32 of the children (89%) were symptom-free after laser-assisted tonsillotomy with adenotomy. The Brouillette-score improved significantly (p = 0.001), snoring was reduced in 91%, difficulty breathing in 93% and apnea in 100% of the children. The pain of the surgical intervention has been valued by the patient's parents as mild to moderate. Postoperatively 91.6% of the children recovered within 6 days (mean = 4.7 days), no bleeding occurred. Outpatient laser-assisted tonsillotomy with adenotomy can be recommended in children with adenotonsillar hyperplasia and possible obstructive sleep apnea. The surgical intervention is less painful, the children recover more quickly and the results on snoring, difficulty breathing and apnea are equal in comparison to conventional tonsillectomy with adenotomy. In addition the recommended procedure shows less post-operative complications.

THYMIC AND ADENOTONSILLAR ENLARGEMENT AFTER SUCCESSFUL TREATMENT OF MALIGNANCIES

Anterior mediastinal and adenoid masses in children after cessation of chemotherapy for malignant disease often cause a diagnostic problem. Differential diagnosis of thymic enlargement and adenoid hyperplasia from recurrence frequently poses a challenge both for the radiologist and the physician. In this study the authors evaluated 491 patients with different malignant tumors for thymic and adenoid hyperplasia. Thymic hyperplasia was seen in 18 patients (5 Hodgkin disease (HD), 5 non-Hodgkin lymphoma (NHL), 4 Wilms tumor, 2 germ cell tumor, 1 Ewing sarcoma, and 1 neuroblastoma), only adenotonsillar hyperplasia was seen in 6 patients, all with NHL, and both thymic and adenotonsillar hyperplasia were seen in 3 patients (1 HD, 2 NHL). In 5 patients, adenoid hyperplasia was proven by biopsy; 1 patient underwent to adenoidectomy. Their histopathologic investigation showed polyclonal follicular hyperplasia. The authors recommend that patients with thymic and/or adenotonsillar enlargement after successful treatment of their primary malignancy should be evaluated cautiously before an invasive procedure is planned.

Respiração oral na criança: repercussões diferentes de acordo com o diagnóstico

A respiração oral é um sintoma freqüente na infância. A síndrome do respirador oral caracteriza-se por cansaço freqüente, sonolência diurna, adinamia, baixo apetite, enurese noturna e até déficit de aprendizado e atenção. Entretanto este sintoma apresenta diversas causas. Faz-se necessário, portanto, esclarecer detalhes sobre estes aspectos clínicos de acordo com suas causas. OBJETIVO: Comparar os achados de sonolência diurna, cefaléia, agitação noturna, enurese, problemas escolares e bruxismo em indivíduos com respiração oral; de acordo com os seguintes diagnósticos: rinite alérgica, hiperplasia adenoideana, hiperplasia adenoamigdaliana. FORMA DE ESTUDO: Estudo de coorte transversal. MATERIAL E MÉTODO: Estudo prospectivo com 142 pacientes de 2 a 16 anos, classificados em três grupos: rinite alérgica, hiperplasia adenoideana isolada e hiperplasia adenoamigdaliana. Os responsáveis dos pacientes responderam a questionário padronizado sobre os sintomas noturnos para caracterização da presença de apnéia do sono e sobre os aspectos estudados: cefaléia matinal, desempenho escolar e atenção, sonolência diurna, agitação noturna, enurese, bruxismo. RESULTADOS: A respiração oral é mais freqüente em meninos. Crianças com hiperplasia adenoamigdaliana são mais jovens. Este grupo apresenta maior freqüência de roncos e apnéia do sono, assim como mau desempenho escolar, bruxismo, enurese e agitação noturna, sendo estes sintomas relacionados com a apnéia, diferenciando-se do grupo com rinite alérgica. Não se observou sonolência diurna e cefaléia matinal significante nos grupos estudados. CONCLUSÃO: Bruxismo, enurese, agitação noturna e cefaléia estão relacionados com a apnéia do sono, sendo mais freqüente na hiperplasia adenoamigdaliana. Assim, a investigação de apnéia do sono na criança com respiração oral é fundamental e assim como a determinação da causa da respiração oral.

Sleep-associated respiratory disorders in childhood

Sleep-related breathing disorders in children are common. Nearly 10% of preschool-aged children snore, and 1% of 4- to 5-year-old children present with an obstructive sleep apnea syndrome (OSAS), mostly due to an adenotonsillar hyperplasia. OSAS in children differs markedly from adults concerning etiology, clinical symptoms, polysomnographic findings, and course of the disease. Therefore, results of adult sleep medicine cannot easily be applied to children. The disease may result in pulmonary or systemic hypertension, failure to thrive, and neurocognitive misbehavior. Up to now, there is no consensus concerning diagnosis and therapy. In this article, we summarize and discuss what is known so far about sleep-related breathing disorders in children, focussing on the OSAS as the most important diagnosis for the ENT specialist.

Effect of common airway manoeuvres on upper airway dimensions and clinical signs in anaesthetized, spontaneously breathing children

Chin lift, jaw thrust and these manoeuvres combined with continuous positive airway pressure (CPAP) can be used to improve the patency of the upper airway during general anaesthesia. We used video endoscopy and measurement of stridor to compare the efficacy of these manoeuvres in 24 children (3-10 yr) with adenotonsillar hyperplasia. A bronchofibrescope was passed via the nose while the children were breathing spontaneously, to identify (i) the shortest transverse distance between the tonsils during inspiration and during expiration and (ii) the distance from the tip of the epiglottis to the posterior pharyngeal wall. Chin lift or jaw thrust lifted the epiglottis and, when combined with CPAP (10 cm H2O), there was a significant lateral displacement of the tonsils. Both chin lift plus CPAP and jaw thrust plus CPAP reduced stridor significantly compared with the unsupported condition. In conclusion, in spontaneously breathing children with large tonsils, chin lift plus CPAP is recommended, whereas jaw thrust plus CPAP is no better and may cause post-operative discomfort.

Digital signal analysis of snoring sounds in children

Snoring sounds of 5 children with sleep-dependent compromised breathing were recorded. Underlying diseases were large adenoids, adeno-tonsillar hyperplasia, hemangioma of the tongue-base and Rubinstein-Taybi's syndrome associated with micrognathia. For comparison snoring sounds of a 42-year-old chronic snorer were analyzed. Time series of the power spectral density of the breath sounds were calculated as well as the mean power spectra of the recordings. The results show that the frequency spectrum reflects the pathomechanism responsible for the production of the abnormal breath sound. In adults, simple snoring is due in large part to vibrations of the soft palate. This can be identified in the frequency spectrum as a low-frequency component with a large number of harmonics. In children with enlarged adenoids and tonsils the soft palate is impeded in its movement which can be demonstrated in the frequency spectrum as a lack of low-frequency components and harmonics. Craniofacial anomalies are characterized by special spectral patterns.

Sleep Disorders and Airway Obstruction in Children

Obstructive sleep disorders in children are not rare. Many parents will provide sufficient history to establish the diagnosis. Although there may be many causes of obstructive disorders, the most common in children is adenotonsillar hyperplasia. Aggressive treatment will result in prompt resolution of symptoms.