Adenotonsillectomy For Obstructive Sleep Apnea Research Articles

0614 Comparison and Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Children with Achondroplasia

0614 Comparison and Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Children with Achondroplasia

Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits.

To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p<0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p=0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p=0.002) and EDACS<3 (p=0.031). Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.

Preoperative continuous positive airway pressure use improves the hospital experience of children undergoing adenotonsillectomy for obstructive sleep apnea

Background: Objective of the study was to determine how the preoperative use of continuous positive airway pressure (CPAP) in children diagnosed with obstructive sleep apnea (OSA), and their compliance with the therapy, impact perioperative outcomes of adenotonsillectomy. Methods: A retrospective chart review was conducted on patients diagnosed with OSA on polysomnography, who underwent adenotonsillectomy between 2011-2017. Comparisons were made between patients who were not prescribed CPAP (N-CPAP), prescribed CPAP but non-compliant (NC-CPAP), and those compliant with their CPAP prescription (C-CPAP) therapy. OSA severity was categorized by total apnea-hypopnea index into mild &lt;5, moderate 5-10, and severe &gt;10.   Results: A total of 55 of the 162 patients (34%) were recommended CPAP. For those recommended CPAP, 25 were NC-CPAP and 30 C-CPAP. Compared to N-CPAP, NC-CPAP had a 47% reduction in wait time to surgery (p=0.0008) but 59% increase in LOS (p=0.001), while C-CPAP had 24% reduction in wait time (p=0.12) but 34% increase in LOS (p=0.026). Risk for post-operative admission to pediatric intensive care unit (PICU) was highest in NC-CPAP (OR=12 CI 3-44) and increased in C-CPAP (OR=9 CI 2-33). Children with severe OSA had higher frequency of postoperative CPAP use, NC-CPAP 29% and C-CPAP 64% (p≤0.0001). However, use of CPAP did not prevent a requirement for post-operative oxygen. Conclusions: Amongst children prescribed pre-operative CPAP, compliance with therapy had a positive impact on the patient hospital experience following adenotonsillectomy.

The Effects of Adenotonsillectomy for Obstructive Sleep Apnea on Growth Trajectory in Children With Obesity.

To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory. Retrospective review. Tertiary Children's Hospital. Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95 ) data. Covariates included demographic variables, pre- and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits. A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P < .05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P < .001). Preoperative obesity visits, however, were not significantly associated with postoperative growth. The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes. The level of evidence: 3.

How common are ear, nose and throat disorders in children with Noonan syndrome and other RASopathies?

Noonan syndrome and related conditions (RASopathies) are known to be associated with abnormalities in many organ systems. It is our impression that few otolaryngologists are familiar with the manifestations of these syndromes and we therefore reviewed our hospital's patient cohort to identify the prevalence of ear, nose and throat disorders in these children. We cross-referenced various hospital department databases (otolaryngology, audiology, cardiology, haematology and genetics) to try to identify as many children with Noonan and other RASopathies as possible. We then performed a retrospective review of electronic patient records. We identified 67 children with Noonan, Costello, LEOPARD and other RASopathy syndromes. Around half have been seen in otolaryngology and audiology clinics. Otitis media with effusion requiring ventilation tubes occurred in 4% of children. 10% have suffered recurrent acute otitis media. 9% have a sensorineural hearing loss. 7% have undergone adenotonsillectomy for obstructive sleep apnoea. Airway anomalies and head and neck malformations occur but are rare. Children with Noonan and other RASopathies present commonly to otolaryngology and audiology clinics. The prevalence of sensorineural hearing loss is high and audiological screening is likely to be worthwhile. Surgeons should be aware that complications of surgery are common and can be very severe, especially in those with cardiac anomalies.

Predictors of overnight postoperative respiratory complications in obese children undergoing adenotonsillectomy for obstructive sleep apnea.

Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A. A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O2 desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications. Lower O2 saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR=0.953, 95% CI=0.91-0.99, P=0.021), as was sleep time with O2 saturation less than 90% (OR=1.04, 95% CI=1.00-1.07, P=0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O2 saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O2 < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event. O2 saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O2 saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O2 sat <90% during PSG due to increased risk of overnight postoperative respiratory complications.

Cost-minimisation analysis of polysomnography and pulse oximetry in a risk stratification protocol for paediatric adenotonsillectomy.

Severe obstructive sleep apnoea (OSA) is associated with increased risk of respiratory compromise in the post-operative period following adenotonsillectomy (AT). This study analyses the economic cost of polysomnography or overnight oximetry as part of pre-operative risk stratification in paediatric AT, supplementing previously published research demonstrating the efficacy of this protocol in predicting respiratory complications. This cost-minimisation analysis examines costs associated with pre-operative overnight oximetry and polysomnography in triaging paediatric patients older than 2 years old, with no major comorbidities except for OSA, undergoing AT for OSA (n=1801) to either a secondary or quaternary Australian hospital. Decision analysis modelling via probability trees were utilized to estimate pre- and peri-operative costs. A third hypothetical 'no investigation' model based upon conducting all AT at a secondary hospital was performed. Costs are derived from the financial year 2020-2021, censored at discharge. The total cost per patient of AT including pre-operative investigations of oximetry and polysomnography, and associated inpatient costs, were AUD4181.34 and 5013.99 respectively. This is more expensive compared to a hypothetical no-investigation model (AUD3958.98). Within the scope of this partial economic evaluation, this study finds a small additional cost for a model of care involving overnight oximetry as a pre-operative triage tool, balanced by the reduced cost of care in a lower acuity centre for low-risk patients and potential high cost of complications if all children are treated in a low acuity centre. This supports oximetry in peri-operative risk stratification for paediatric AT from a financial perspective.

0793 Postoperative Monitoring in Children less than 2 years of Age undergoing Adenotonsillectomy for Obstructive Sleep Apnea

Abstract Introduction To analyze variables associated with postoperative monitoring in children &amp;lt;2 years of age undergoing adenotonsillectomy (T&amp;A) for the management of obstructive sleep apnea (OSA). Methods Retrospective case series of children &amp;lt;2 years of age who underwent T&amp;A for the management of OSA between 1/1/08-6/1/18. Postoperative respiratory complications and hospital course were analyzed to determine higher acuity of monitoring in Intensive Care Unit (ICU) versus observation unit was indicated. Results A total of 69 children were analyzed. Fifty-two (75.4%) patients were male, and their mean age was 18.8 months. Fifty-six (81.2%) children had severe OSA, 6 (8.7%) had moderate OSA, and 7 (10.1%) children had mild OSA. Thirty-seven (53.6%) children were monitored in the ICU; one (2.7%) child was admitted to the ICU directly from the sleep lab, and3 (8.1%) children were intubated. The average Apnea Hypopnea Index (AHI) for those who were intubated was 64.6 events/hour and low SpO2 average was 66.3%, when compared to an average of 36.2 events/hour and 75.5% respectively for the entire group. Three (8.1%) patients needed &amp;gt;2 liters/minute of O2, and 5 (13.5%) had minor O2 requirements. Only 7/32 (21.9%) patients monitored in the observation unit required supplemental O2. Conclusion A greater severity of AHI and low SpO2 nadir were associated with respiratory issues requiring monitoring of children in ICU after T&amp;A for OSA. No specific PSG cut-off values for ICU versus observation unit were noted. Low incidences of respiratory issues were observed, and most children could have been monitored safely outside of the ICU setting. Support (If Any) None

Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Children Under 3 Years of Age.

Objectives: To identify predictors of obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) in children under 3years of age and to describe the characteristics of children with OSA under 3years of age undergoing T&A in an ethnically diverse population. Methods: We examined 87 children under 3years with T&A and pre- and post-operative polysomnography (PSG) between 8/2012 and 3/2020 at a large tertiary care hospital. Differences were compared for covariates including demographics, comorbidities, and respiratory parameters. Regression was used to identify predictors of persistent severe OSA. Significance was set at P < .05. Results: Of the 87 children in the study, 64 (74%) were male, 26 (30%) were obese, 34 (39%) were Hispanic, and 35 (40%) were Black. Most children (94%) had improvements in OSA severity as measured by the apnea-hypopnea index (AHI) after T&A, but 78% had persistent OSA (AHI ≥1) after surgery. Children with persistent mild, compared to moderate-severe OSA, were more likely to have gastroesophageal reflux disease (GERD) (50% versus 24%, P = .025), a craniofacial disorder (30% versus 10%, P = .025), Down syndrome (20% versus 5%, P = .031), or pre-operative severe OSA. Conclusions: This study of an ethnically diverse population found that T&A is an effective procedure at improving, but not resolving, OSA in children under 3years. Children with Down syndrome, craniofacial abnormalities, GERD, or pre-operative severe OSA who are under 3years old are at high risk for persistent OSA and may benefit from post-operative PSG. Future study should examine complications and long-term outcomes of T&A in this age group.

Adenotonsillectomy for the treatment of obstructive sleep apnoea in extreme paediatric obesity.

Adenotonsillectomy is a recognised treatment for paediatric obstructive sleep apnoea. Recent literature highlights the need to assess outcomes in the extremely obese subpopulation. This study reviewed the efficacy of adenotonsillectomy performed in patients with extreme obesity. A retrospective analysis of attendees at a tertiary paediatric obesity clinic was performed, identifying patients with a body mass index z-score equal to or more than three who had undergone adenotonsillectomy for obstructive sleep apnoea. Electronic patient records, including respiratory polygraphy, were analysed. Nine patients met the study criteria. All required nocturnal non-invasive ventilation pre-operatively. Mean age at referral was 6.9 years, and average age of non-invasive ventilation commencement was 7.8 years. Post-operatively, 8 patients (89 per cent) required non-invasive ventilation with evidence of post-operative obstructive sleep apnoea. In extreme obesity, adenotonsillectomy does not prevent the need for non-invasive ventilation. Management of this patient group requires treatment of obesity alongside potential surgical intervention. Poor efficacy in treating obstructive sleep apnoea may influence the decision to proceed with adenotonsillectomy.

Growth After Adenotonsillectomy for Obstructive Sleep Apnea: Revisited.

To reanalyze the growth trajectory and assess longitudinal changes of children undergoing adenotonsillectomy (AT) versus watchful waiting (WW) enrolled in the Childhood Adenotonsillectomy Trial (CHAT) study and to determine if an AT increases the risk of obesity in children. Reanalysis of prospective cohort investigation. The study analyzed publicly available data from CHAT, including 3 months visit data not previously included in a prior publication. Statistical comparisons and mixed-effects modeling were done using age- and sex-specific BMI expressed as a percentage of the 95th percentile (%BMIp95). P < .05 was considered significant. Children in the AT group, especially if underweight at baseline, had an increased rate of weight gain, with 100% of underweight children in the AT group becoming normal weight compared to 20% for WW. However, the rate of weight gain, as measured by the %BMIp95 trajectory for both AT and WW groups, was not significantly different when baseline weight status and obstructive sleep apnea (OSA) resolution were accounted for. Comparisons of %BMIp95 between treatment groups at baseline, 3- and 7-month follow-up visits also failed to identify statistically significant differences (P > .05). Overall for the entire cohort, resolution of OSA was associated with a decreased weight trajectory (P < .001). AT compared to WW is not associated with an increased risk of excessive weight gain. Otolaryngologists should be aware of this updated analysis when discussing AT surgical outcomes with families. 2 Laryngoscope, 132:1289-1294, 2022.

Geographic disparities in performance of pediatric polysomnography to diagnose obstructive sleep apnea in a universal access health care system

BackgroundDiagnostic polysomnography (PSG) is recommended prior to adenotonsillectomy (AT) for children with obstructive sleep apnea (OSA) and certain high-risk characteristics, but resource limitations often prevent this practice. ObjectiveWe performed a population-based assessment of children across Ontario, Canada to describe and quantify disparities in PSG. Methods and materialsThis retrospective cohort study was performed using provincial health administrative data held at ICES. We identified children 0–10 years old who underwent PSG and AT between 2009 and 2018, and those with a PSG within 18 months prior to and/or 12 months following AT. We calculated the odds of PSG prior to/following AT after adjustment for demographics, medical comorbidities, geographic and socioeconomic characteristics. Our main predictor was driving time/distance to the nearest pediatric sleep centre ascertained using spatial analysis and geographic information systems. ResultsWe identified 27,837 children <10 years old who underwent AT for OSA in Ontario. Only 12.8% had a PSG within 18 months prior and 5.7% had a PSG within 12 months following AT. Shorter driving time/distance, older age, male sex and certain comorbidities were associated with increased odds of PSG. ConclusionOnly a small proportion of children in our cohort underwent PSG prior to or following AT surgery despite universal access to healthcare. This study suggests a need to increase overall PSG access, particularly for those living distant from existing pediatric sleep centres. Future studies could determine if increased PSG testing in ‘underserviced areas’ would reduce overall surgery rates and/or improve health outcomes.

Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Prader-Willi Syndrome: Systematic Review and Meta-analysis.

Prader-Willi syndrome (PWS) increases the risk of obstructive sleep apnea (OSA) due to obesity, hypotonia, and abnormal ventilatory responses. We evaluated post-adenotonsillectomy complications, polysomnography changes, and quality of life in children with OSA and PWS. Systematic review and meta-analysis. We conducted a systematic review and meta-analysis by searching PubMed, Embase, Cochrane, Web of Science, and Scopus. Two researchers independently reviewed studies about adenotonsillectomy for OSA in patients <21 years with PWS. We extracted study design, patient numbers, age, complications, polysomnography, and quality of life. We pooled postoperative changes in apnea hypopnea index (AHI) for meta-analysis. We applied Methodological Index for Nonrandomized Studies (MINORS) criteria to assess study quality. The initial search yielded 169 studies. We included 68 patients from eight studies with moderate to high risk of bias. Six studies reported on complications and 12 of 51 patients (24%) had at least one. Velopharyngeal insufficiency was the most commonly reported complication (7/51, 14%). We included seven studies in meta-analysis. Mean postoperative improvement in AHI was 7.7 (95% CI: 4.9-10.5). Postoperatively 20% (95% CI: 3%-43%) had resolution of OSA with AHI < 1.5 while 67% (95% CI: 50%-82%) had improvement from severe/moderate OSA to mild/resolved (AHI < 5). Two studies evaluated quality of life and demonstrated improvement. Children with PWS undergoing adenotonsillectomy for OSA have a substantial risk of postoperative complications that may require additional interventions, especially velopharyngeal insufficiency. Despite improvements in polysomnography and quality of life, many patients had residual OSA. This information can be used to counsel families when considering OSA treatment options. Laryngoscope, 131:898-906, 2021.

Polysomnography variables associated with postoperative respiratory issues in children

ObjectivesTo determine the polysomnogram (PSG) variables associated with increased incidence of postoperative respiratory complications in children <3 years of age undergoing adenotonsillectomy (T&A) for the management of obstructive sleep apnea (OSA). MethodsRetrospective case series of children <3 years of age who underwent T&A for the management of OSA at a tertiary care children's hospital from 1/1/08–6/1/2018. Postoperative hospital courses were analyzed to determine if certain clinical or PSG variables might have predicted an increased rate of respiratory complications. ResultsA total of 195 children <3 years of age with OSA on preoperative PSGs underwent T&A. The mean age of patients was 25.8 months (range 9–35 months). Seventeen patients (16.2%) had mild OSA, 35 (17.9%) had moderate, and 141 (72.3%) had severe OSA. Most patients (n = 155, 79.5%) required no respiratory intervention postoperatively. Those with severe OSA were more likely to require oxygen support (n = 25, 17.7%) when compared to those with mild-moderate OSA (n = 3, 5.6%). Patients admitted directly to the pediatric intensive care unit (PICU) from the sleep lab (n = 7) had a mean apnea-hypopnea index (AHI) of 63.6 events/hour (range 23–146/hr.), and a mean SpO2 nadir of 56.3% (range 46–68%). Four of these patients required CPAP after T&A. Of the 7 patients (3.6%) who required intubation after their procedure, only 1 did not have severe OSA, and 2 were intubated to manage post-obstructive pulmonary edema (POPE). Only 4 patients (4.2%) had unplanned PICU admissions. An AHI >12.7 events/hour, >18.5 obstructive apneas, and SpO2 nadir <72.5% were associated with a greater likelihood of requiring postoperative respiratory interventions. ConclusionsMost children <3 years of age, even with severe OSA, had no respiratory issues postoperatively. Those with severe OSA and hypoxemia admitted directly from the sleep lab were more likely to require CPAP postoperatively. All but one patient who developed POPE or who required intubation had severe OSA with associated hypoxemia on their preoperative PSGs.

Cognition After Early Tonsillectomy for Mild OSA.

It remains uncertain whether treatment with adenotonsillectomy for obstructive sleep apnea in children improves cognitive function. The Preschool Obstructive Sleep Apnea Tonsillectomy and Adenoidectomy study was a prospective randomized controlled study in which researchers evaluated outcomes 12 months after adenotonsillectomy compared with no surgery in preschool children symptomatic for obstructive sleep apnea. A total of 190 children (age 3-5 years) were randomly assigned to early adenotonsillectomy (within 2 months) or to routine wait lists (12-month wait, no adenotonsillectomy [NoAT]). Baseline and 12-month assessments included cognitive and behavioral testing, medical assessment, polysomnography, and audiology. The primary outcome was global IQ at 12-month follow-up, measured by the Woodcock Johnson III Brief Intellectual Ability (BIA). Questionnaires included the Pediatric Sleep Questionnaire, Parent Rating Scale of the Behavioral Assessment System for Children-II, and Behavior Rating Inventory of Executive Function, Preschool Version. A total of 141 children (75.8%) attended baseline and 12-month assessments, and BIA was obtained at baseline and 12-month follow-up for 61 and 60 participants in the adenotonsillectomy versus NoAT groups, respectively. No cognitive gain was found after adenotonsillectomy compared with NoAT, adjusted for baseline; BIA scores at 12-month follow-up were as follows: adenotonsillectomy, 465.46 (17.9) versus NoAT, 463.12 (16.6) (mean [SD]). Improvements were seen for polysomnogram arousals and apnea indices and for parent reports of symptoms (Pediatric Sleep Questionnaire), behavior (Behavior Assessment System for Children behavioral symptoms, P = .04), overall health, and daytime napping. Structured testing showed no treatment-attributable improvement in cognitive functioning of preschool children 12 months after adenotonsillectomy compared with NoAT. Improvements were seen after adenotonsillectomy in sleep and behavior by using polysomnogram monitoring and parental questionnaires.

Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population.

Objective To determine the prevalence of respiratory complications in the early postoperative period of children with sleep apnea who required adenotonsillectomy at a tertiary pediatric hospital and to establish recommendations for postoperative monitoring. Methods Retrospective cohort study of children with obstructive sleep apnea (OSA) diagnosed by polysomnogram (PSG), who underwent adenotonsillectomy for treatment of OSA. The prevalence of respiratory complications in the first 24 postoperative hours was measured. Patients with craniofacial malformations, obesity, and severe cardiovascular comorbidities were excluded. The prevalence of postoperative respiratory complications was compared with the severity of OSA according to the Apnea Hypopnea Index (AHI) and NADIR. All data were taken in patients residing in Bogotá city, Colombia, at 2.640 meters above sea level (m.a.s.l). Results Between May 2014 and February 2017, 167 patients (108 males) required adenotonsillectomy for OSA, with an age range of 1 and 15 years (mean 5.3 years +/- 2.7). The prevalence of postoperative respiratory complications was 3.59% (6/167). There was a statistically significant relationship between the presence of respiratory complication and AHI greater than 44/h (p <0.04). There was an inverse correlation between the AHI and NADIR values. Risk groups of patients younger than 3 years and NADIR less than 70% had a higher prevalence of respiratory complications; however, this correlation was not statistically significant (p <0.08 and 0.89, respectively). Conclusions The prevalence of respiratory complications in OSA patients undergoing adenotonsillectomy in high altitudes is similar to that reported in other heights. Preoperative AHI greater than 44/h could be considered a risk factor for early respiratory complication. We suggest ambulatory management after 6 hours in Postanesthetic Care Unit (PACU) observation in patients older than 3 years, with AHI less than 44/h and NADIR greater than 70% in altitudes higher than 2.500 m.a.s.l. Further research must be done to confirm this hypothesis.

Predictors of Obtaining Polysomnography Among Otolaryngologists Prior to Adenotonsillectomy for Childhood Sleep-Disordered Breathing.

(1) To assess the predictors for obtaining polysomnography (PSG) in children undergoing adenotonsillectomy (AT) for sleep-disordered breathing, and (2) to estimate the adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline recommendations for pre-AT PSG. This was a retrospective cohort study of children who were seen in the Pediatric Otolaryngology Clinic and underwent AT for sleep-disordered breathing over a 13-month period at a single tertiary care children's hospital. Patients with and without pre-AT PSG were compared using bivariate and logistic regression analysis to identify predictors for PSG. Electronic medical records were reviewed for demographic variables, medical comorbidities, and PSG data. Adherence to AAO-HNS guideline recommendations was estimated by calculating the proportion of patients who had a PSG among those who met the recommended criteria for pre-AT PSG. Mean age was 6.6 ± 3.6 years with 53% male. A total of 65 of 324 children (20%) underwent PSG prior to AT. The only factor significantly associated with pre-AT PSG was age 1 to 3 years (odds ratio 4.5, 95% confidence interval [2.2, 9.0], P < .001). Among patients who met AAO-HNS criteria for pre-AT PSG, 28 of 128 (20%) underwent PSG compared to 35 of 186 (19%) who did not meet criteria (odds ratio 1.0, 95% confidence interval [0.6, 1.9], P = .87). Among children who underwent AT, the only significant predictor of obtaining pre-AT PSG was age 1 to 3 years. The rate of adherence to the AAO-HNS guideline recommendations was low (20%), which represents an educational opportunity.

Day case adenotonsillectomy for paediatric obstructive sleep apnoea: a review of the evidence.

Tonsillectomy and adenoidectomy are two of the most commonly performed procedures by otolaryngologist, especially in the paediatric population. Most common indications for adenotonsillectomy in the paediatric population include recurrent tonsillitis, otitis media (glue ear) and obstructive sleep apnoea (OSA). Whilst adenotonsillectomy is routinely performed as a day case for recurrent tonsillitis, many surgeons advocate an overnight stay for patients for OSA. The practice of keeping these patients in overnight for saturation monitoring is widely undertaken. There has been some dispute as to whether this is required. This review sets out to consider the evidence supporting the safety of day case adenotonsillectomies for paediatric obstructive sleep apnoea (OSA). The available literature between 2004 and 2017 was reviewed via searches on Pubmed, Medline, EMBASE and Google Scholar. The search terms used were: Adenotonsillectomy, day case, paediatric, obstructive sleep apnoea, and complications. A literature search identified 31 articles that were relevant to our review. After screening six articles were appropriate for inclusion in this review paper, all were retrospective reviews of case notes. 1463 children out of 1992 (including at least 207 children with comorbidities who were kept overnight) children had day case adenotonsillectomy for obstructive sleep apnoea. Tonsillectomy techniques were not discussed in any of the papers. Day case adenotonsillectomy for children between 3 and 17years who appears to be a safe option with a growing body of evidence. Large randomised control trials would likely add weight to this conclusion and help change the mind-set of clinicians.

Obstructive Sleep Apnea in the Very Young

The aim of this report was to review the recent literature related to the assessment and management of obstructive sleep apnea (OSA) in children under the age of 2 years. Adenotonsillectomy (AT) indications are changing, with a greater proportion of younger children undergoing AT for OSA. Medical therapies may be an alternative to AT in mild-moderate OSA cases; however, further research is needed. Coblation® intracapsular tonsillectomy may confer benefits in reduced post-operative pain and hemorrhage. Recent concerns regarding the safety of general anesthesia in young children are an important area for further investigation. There is a paucity of literature related to OSA in children younger than 2 years. Recent large-scale trials have actively excluded children from this age group and there are no planned studies of this specific population. These children represent a distinct population with differing etiologies, presentations, investigations, and management consideration.

Adenotonsillectomy for Obstructive Sleep Apnea in Children with Complex Chronic Conditions.

Objective To estimate the prevalence of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Study Design A retrospective cohort study. Setting The Hospital for Sick Children Sleep laboratory. Subjects Children ≤18 years of age who had moderate to severe obstructive sleep apnea and had polysomnography pre- and postadenotonsillectomy. Methods Medical and polysomnographic data were reviewed. The prevalence of persistent obstructive sleep apnea postadenotonsillectomy was determined for the following groups: no complex chronic conditions, single-system complex chronic conditions, and multisystem complex chronic conditions. Results We reviewed data of 133 (84 male) children. Their mean (standard deviation) age was 5.5 (3.8) years. The persistent obstructive sleep apnea rate postadenotonsillectomy was highest in children with multisystem complex chronic conditions (57%), intermediate in children with single-system complex chronic conditions (29%), and lowest in children without complex chronic conditions (15%), P = .0004. The odds (confidence interval) of having persistent obstructive sleep apnea postadenotonsillectomy was 7.42 (2.16-25.51) times higher in children with multisystem complex chronic conditions vs no complex chronic conditions and 3.35 (1.16-9.64) times higher in children with multisystem complex chronic conditions vs single-system complex chronic conditions. Conclusions Although adenotonsillectomy is considered first-line therapy in healthy children older than 2 years for the treatment of obstructive sleep apnea, there is a significantly greater risk of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Therefore, other surgical procedures or nonsurgical management may need to be considered as first-line treatment for this cohort.