After Adenotonsillectomy Research Articles

Postoperative Respiratory Complications After Adenotonsillectomy in Children With High-Risk Obstructive Sleep Apnea.

Identify patient characteristics and polysomnogram (PSG) parameters associated with postoperative respiratory complications after adenotonsillectomy (AT) among children with high-risk obstructive sleep apnea (OSA). Case series with chart review. Tertiary care children's hospital. Pediatric patients (<18 years) with high-risk OSA (any 1 of: apnea-hypopnea index [AHI] >30, O2 nadir <80% and peak CO2 >60 mm Hg) on overnight PSG from 2019 to 2021 were included. Primary outcomes were major respiratory intervention during the postoperative admission, prolonged hospitalization, and intensive care unit (ICU) stay. A total of 307 patients met inclusion criteria. Median age was 6.5 years and 63% were male. Twenty-five (8.1%) required major respiratory intervention and 29 (9.7%) required ICU admission after AT. Major interventions and ICU admissions were significantly associated with neuromuscular disease (P < .01), higher obstructive apnea-hypopnea index (oAHI), higher CO2 peak, and lower O2 nadir. Prolonged admission had similar findings except oAHI was not significantly associated. Younger children were significant more likely to require ICU admission or prolonged admission. Increased oAHI and worsening O2 and CO2 parameters on preoperative PSG were associated with postoperative respiratory complications in children with high-risk OSA. Children with neuromuscular disease and age 0 to 2 had higher risk of ICU stay and prolonged hospitalization. Clinicians should recognize the importance of parameters beyond oAHI when anticipating postoperative monitoring.

Drug-Induced Sleep Endoscopy Predicts Subjective Outcomes of Adenotonsillectomy.

Persistent obstructive sleep apnea (OSA) after adenotonsillectomy (AT) has been reported in 20%-30% of children. The aim of this study was to determine the predictive value of drug-induced sleep endoscopy (DISE) at the time of AT on subjective AT outcomes. This was a prospective cohort study of children aged 2-18 years being treated with AT for sleep disordered breathing (SDB) with one or more risk factors for AT failure: age >7 years, obesity, severe baseline OSA, Black race. All underwent DISE at the time of AT. Potential predictors of subjective AT outcome included age, sex, obesity, and DISE patterns. Multivariable linear regression was used to model predictors of post-AT Pediatric Sleep Questionnaire (PSQ) and OSA-18 outcomes. Pre- and post-AT PSQ/OSA-18 responses were available from 194 children. Mean age was 9.3 ± 3.5 years, with 59% obese, 50% female, and 67% White. After AT, mean PSQ score decreased from 0.60 ± 0.19 to 0.28 ± 0.22, p < 0.001 and mean OSA-18 score decreased from 66 ± 21 to 37 ± 18, p < 0.001. The most frequent sites of obstruction were the tonsils (92%), nasal airway (77%), adenoids (64%), and velopharynx (65%). Multivariable regression modeling demonstrated worse outcomes with obesity, male gender, and multilevel obstruction that included the nasal airway and tongue base in addition to adenotonsillar obstruction. Persistent OSA and symptom burden after AT was common in this population. Obesity, male gender, and multilevel obstruction during DISE were all associated with worse subjective outcomes. 3 Laryngoscope, 2024.

Effect of Preoperative Weight Status and Disease Presentation on Postoperative Elevated Blood Pressure After Childhood Adenotonsillectomy.

To investigate the risk factors of postoperative elevated blood pressure (BP) in children with childhood obstructive sleep apnea syndrome (OSAS) after adenotonsillectomy (AT). Case series with planned data collection. Tertiary referral center. Two hundred forty-five consecutive children (180 boys and 65 girls, median age 6.6 years) with polysomnography-diagnosed OSAS who underwent AT between January 2010 and August 2019. Clinical, polysomnographic, and evening BP data were assessed preoperatively and postoperatively (≥3 months after AT). Changes in the variables before and after AT and between individuals with and without hypertension were compared. Postoperatively, the median (interquartile range) apnea-hypopnea index significantly decreased from 10.4 (5.3-22.6) to 2.2 (1.0-3.8) events/h. In addition, the mean (standard deviation) evening diastolic BP z-score significantly decreased from 0.7 (0.94) to 0.5 (0.81) in the overall cohort, and both systolic (2.1 [0.94]-1.0 [1.31]) and diastolic BP z-scores (1.6 [0.98]-0.7 [0.85]) significantly decreased in the preoperative elevated BP subgroup. Multivariate logistic regression analysis showed that preoperative obesity (adjusted odds ratio = 4.36, 95% confidence interval = 2.24-8.49) and mean peripheral oxygen saturation <95% during sleep (adjusted odds ratio = 2.73, 95% confidence interval = 1.29-5.79) were independently associated with postoperative elevated BP. Preoperative obesity and mean peripheral oxygen saturation <95% during sleep were significantly associated with postoperative elevated BP in the children with OSAS, further indicating the importance of careful BP monitoring in this subgroup despite AT treatment.

OSAHS Growth Impairment and Resolution after Adenotonsillectomy in Children.

Introduction:One of the most important complications of OSAHS in children is growth delay. The aim of this study was to investigate changes in clinical body growth, and laboratory growth in children with OSAHS after adeno-tonsillar surgery.Materials and Methods:In our study, among 102 children suffering from sleep-disordered breathing, 70 met the inclusion criteria because they were affected by OSAHS and adenotonsillar hypertrophy. In total, 96 children affected by adeno-tonsillar hypertrophy (55 males and 41 females) underwent nocturnal cardiorespiratory monitoring with Embletta MPR, monitoring for post-operative 24 hours. Patients underwent blood sampling to evaluate preoperative GH and IGF-1 serum levels, “placement” in Cacciari’s growth charts and adenotonsillectomy and saturation monitoring for post-operative 24 hours. According to auxological parameters, 82.86% of the patients were below the fiftieth percentile of BMI Cacciari’s growth charts and IGF-1 preoperative serum levels were below the normal range. All patients underwent adenotonsillectomy. Results:All 70 patients recovered from OSAHS according to the results of nocturnal cardiorespiratory monitoring after six months. IGF-1 serum levels significantly increased after three months and one year after. All the auxological parameters showed a significant increase after surgery. We calculated the average annual growth in height of the patients before and after adenotonsillectomy (AT): the growth rate was impaired by OSAHS (5.4±1.3 cm/year), while in the following year post-surgery we found a significant growth speed acceleration (9.9±1.7 cm/year, P=0.001). Conclusions:In conclusion, growth delay in children can be caused by OSAHS, and when it is due to adenotonsillar hypertrophy, adenotonsillectomy is to be considered as the therapy of choice.

Biomarkers of pediatric obstructive sleep apnea syndrome and the assessment of quality of life before and after adenotonsillectomy.

The study aims to explore the inflammatory cytokines and oxidative stress in children with obstructive sleep apnea syndrome (OSAS) triggered by adenoids and/or tonsillar hypertrophy and their changes after adenotonsillectomy (AT) and to investigate the associated behavioral disorders in OSAS, before and after AT. Thirty patients with OSAS and 20 healthy children, aged 3 - 13 years were included in the study. According to apnea-hypopnea index (AHI), OSAS children were classified into 3 groups: mild (n = 19), moderate (n = 5), and severe OSAS (n = 6). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, malondialdehyde (MDA) and antioxidant enzymes activities were assessed in serum, preoperative and 6 weeks after AT. TNF-α, IL-6 and malondialdehyde levels were also estimated in adenoid and tonsils tissues. A Pediatric Sleep Questionnaire was completed by the parents before and after AT. As a result of the study, we obtained the following results: TNF-α, IL-6 and malondialdehyde evaluated preoperative increased in serum and tissues in OSAS, especially in severe disease compared to mild and moderate forms. Six weeks after AT, AHI diminished significantly in OSAS, as well as the inflammatory markers and malondialdehyde, in parallel with significant improvement of antioxidant enzymes activities. Daytime sleepiness, hyperactivity and attention deficit in OSAS, even in mild disease were present, with significant improvements of obstructive symptoms after AT. We conclude that OSAS caused by adenoids and/or tonsillar hypertrophy led to changes in the blood parameters, with significant improvement after AT. Postoperatively, a significant improvement in sleep quality and behavior in OSAS patients was also observed.

Continuous oximetry recordings on the first post-operative night after pediatric adenotonsillectomy-a case-control study

BackgroundChildren with obstructive sleep apnea (OSA) with recurrent dips in oxygen saturation (SpO2) during sleep are known to be at increased risk of post-operative airway compromise after adenotonsillectomy (AT). We aimed to determine the extent of desaturation on the first post-operative night in children known to have recurrent desaturation pre-operatively and to compare the extent of desaturation in that group with results in children known to have normal oximetry recordings pre-operatively. MethodsProspective sequential recruitment of 57 children who had overnight oximetry performed on the first night after adenotonsillectomy was undertaken, including 28 with a McGill Oximetry Score (MOS) of 2–4 pre-operatively (high risk group) and 29 with a normal/inconclusive pre-operative MOS (low risk group). Oximetry parameters (mean SpO2, SpO2 nadir, and rates of SpO2 dips below 90% and dips of ≥4%) were compared to the pre-operative oximetry result. Demographic and clinical factors, and the occurrence of post-operative complications, were derived from the medical record. ResultsIn the high risk group, the MOS improved in 23/28 children, but remained abnormal in 82%. Conversely, in the low risk group 26/29 (90%) had a normal post-operative oximetry. The remaining 3, all of whom had severe OSA on pre-operative polysomnography, had a lowered baseline SpO2 post-operatively. Mean SpO2 was slightly lower post-operatively in both groups. In the high risk group, all other SpO2 measures improved post-operatively. Respiratory adverse events were more common in the high risk group as expected (39% compared to 3% in the low risk group, p = 0.001). An adverse event requiring clinical intervention was significantly more likely if the post-operative oximetry was abnormal (result unknown to the treating team), occurring in 73% of children with an abnormal compared with 32% of children with a normal post-operative oximetry (p = 0.002). ConclusionMost children with an abnormal oximetry pre-operatively continued to have an abnormal oximetry on the first night after AT, albeit somewhat improved. While adverse events were more frequent in children with an abnormal post-operative oximetry, half (54%) did not suffer a clinical respiratory adverse event despite having repetitive desaturations on downloadable oximetry. These findings support close clinical observation of children at high risk of complications post-operatively, especially those with abnormal oximetry pre-operatively, rather than focusing on recurrent dips in SpO2 on post-operative oximetry downloads in the absence of clinically evident complications.

Polysomnography outcomes of sleep endoscopy-directed intervention in surgically naïve children at risk for persistent obstructive sleep apnea.

Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naïve children is unclear. We report polysomnography outcomes of surgically naïve children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy. This study is a case series of 62 surgically naïve children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test. Children were on average 5.9 (± 5.5, 0.2-18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p < 0.01) and oxygen nadir (82 to 87, p < 0.01). Thirty-eight (61%) had a postoperative oAHI < 5; 16 (21%) had a postoperative oAHI < 2. DISE resulted in intervention other than AT in 58% of surgically naïve children at high risk for persistent OSA after AT. DISE-directed intervention resulted in significant mean improvement in postoperative OSA.

Assessing the need for adenotonsillectomy for sleep-disordered breathing in a community setting: A secondary outcome measures analysis of a randomized controlled study.

To assess whether children with sleep-disordered breathing (SDB) symptom severity above a certain level, measured by a validated questionnaire, improve after adenotonsillectomy (AT) compared to no intervention. Children with snoring and tonsillar hypertrophy (4 to 10-years old), who were candidates for AT, were randomly assigned to two evaluation sequences (baseline and 3-month follow-up): (a) evaluation immediately before AT and at 3 months postoperatively (AT group); or (b) evaluation at the initial visit and at the end of the usual 3-month waiting period for surgery (control group). Outcomes were (a) Pediatric Sleep Questionnaire sleep-related breathing disorder scale (PSQ-SRBD); (b) modified Epworth Sleepiness Scale (mESS); and (c) proportion of subjects achieving PSQ-SRBD <0.33 (low-risk for apnea-hypopnea index ≥5/h) if they had score ≥0.33 at baseline. Sixty-eight children were assigned to the AT and 72 to the control group and two-thirds of them had PSQ-SRBD ≥0.33. The AT group experienced significantly larger improvement between follow-up and baseline than controls (between-group difference [95% CI] for PSQ-SRBD: -0.31 [-0.35 to -0.27]; and mESS: -2.76 [-3.63 to -1.90]; P < .001 for both). Children with baseline PSQ-SRBD ≥0.33 in the AT group had an eight-times higher probability of achieving PSQ-SRBD <0.33 at follow-up than controls with similar baseline score (risk ratio [95% CI]: 8.33 [3.92-17.54]; P < .001). Among children with snoring, tonsillar hypertrophy, and clinical indications for AT, those with preoperative PSQ-SRBD score ≥0.33 show measurable clinical benefit postoperatively.

Bone Age and Serum Osteocalcin Levels in Children With Obstructive Sleep Apnea Hypopnea Syndrome Before and After Adenotonsillectomy.

Our aim was to study the changes in bone age and serum osteocalcin levels before and after adenotonsillectomy (AT) in children with obstructive sleep apnea hypopnea syndrome (OSAHS). A total of 58 OSAHS children (37 males and 21 females) with the mean age of 6.68 ± 1.11 years were enrolled and assessed by x-ray-based bone age estimation and enzyme-linked immunosorbent assay-based measurement of serum osteocalcin levels, before surgery and 6 months after AT. SPSS 19.0 software was used for statistical analysis. Our results revealed that bone age and serum osteocalcin levels in OSAHS patients were significantly lower than normal controls before AT (P < 0.05). Within 6 months after surgery, the bone age and the serum osteocalcin levels were significantly elevated in OSAHS patients (P < 0.05), compared with those before surgery. Serum osteocalcin levels and bone age are negatively correlated with apnea-hypopnea index, oxygen desaturation index, the percentage of the total recorded time spent below 90% oxygen saturation, and Epworth sleepiness scale scores (all P < 0.05). Our findings suggested that bone age and serum osteocalcin levels may be correlated with the development of OSAHS in children. AT may improve bone age and serum osteocalcin levels in OSAHS children.

The impact of adenotonsillectomy on pulmonary arterial pressure in West African children with adenotonsillar hypertrophy

ObjectivesTo assess the improvement or otherwise, in the mean pulmonary arterial pressure (mPAP) among children with adenotonsillar hypertrophy (ATH) after adenotonsillectomy (AT), and to examine the impact of timing of surgery as well as the patients' characteristics on the mPAP changes. MethodsWe included 39 children with ATH in this study. The adenoidal enlargement was evaluated radiologically with adenoid nasopharyngeal ratio (ANR) parameter from lateral neck radiograph, whereas the clinical assessment of adeno-tonsillar obstruction was conducted with the ‘symptom score’. Pulmonary arterial pressure (PAP) measurement was performed noninvasively by Doppler echocardiography. All patients underwent adenotonsillectomy (AT). After 6 weeks, they were subjected again to clinical and echocardiographic assessments, and the mean pulmonary arterial pressures (mPAP) were then compared. The mPAP changes after AT were further related to the grades of ANR, symptom scores, tonsillar size, and timing of AT. ResultsThe preoperative mPAP was 23.46 mmHg and was 18.98 mmHg post-operatively (P = 0.003). Seventeen of subjects (43.6%) had pulmonary hypertension (PH) (mPAP ≥ 25 mmHg) preoperatively, out of which 14 (82%) decreased to normal range 6 weeks after AT. Non-reversal of pulmonary hypertension was associated with ANR > 0.75 (P = 0.043), but was not related to the timing of surgery, tonsillar size, and symptom score. Significant reduction in mPAP was more likely with ANR ≤ 0.75 and pre-operative mPAP ≥ 25 mmHg. All the symptoms also improved significantly after AT. ConclusionElevated PAP due to ATH in children was mostly reversible by AT irrespective of the timing of surgery, symptom severity, and tonsillar size, but gross enlargement of adenoids seem to be associated with non-reversal of PH.

Adaptation and Validation of the Spanish Version of OSA-18, a Quality of Life Questionnaire for Evaluation of Children with Sleep Apnea-Hypopnea Syndrome

ObjectivesTo analyze the reliability and validity of the Spanish version of the OSA-18 quality of life questionnaire in children with apnea-hypopnea syndrome (SAHS). MethodChildren with suspected SAHS were studied with polysomnography (PSG) before and after adenotonsillectomy (AA). Age, gender, clinical data, PSG, anthropometric data, and Mallampati and Brodsky scales were analyzed. OSA-18 was administered at baseline and 3–6months post AA. After translation and backtranslation by bilingual professionals, the internal consistency, reliability, construct validity, concurrent validity, predictive validity and sensitivity to change of the questionnaire was assessed. ResultsIn total, 45 boys and 15 girls were evaluated, showing BMI 18±4, neck 28±5, Brodsky (0: 7%; <25%: 12%; 25%–50%: 27%; >50 to <75%: 45%; >75%: 6%), AHI 12±7 pre AA. Global Cronbach alpha was 0.91. Correlations between domains were significant except for emotional aspects, although the total scores correlated with all domains (0.50–0.90). The factorial analysis was virtually identical to the original structure. The total scores showed good correlation for concurrent validity (0.2–0.45). With regard to predictive validity, the questionnaire adequately differentiated levels of severity according to Mallampati (ANOVA P=.002) and apnea-hypopnea index (ANOVA P=.006). Test-retest reliability was excellent, as was sensitivity to change, both in the total scores (P<.001) and in each domain (P<.001). ConclusionsThe Spanish adaptation of the OSA-18 and its psychometric characteristics suggest that the Spanish version is equivalent to the original and can be used in Spanish-speaking countries.

Multimodality assessment of upper airway obstruction in children with persistent obstructive sleep apnea after adenotonsillectomy.

Children with obstructive sleep apnea (OSA) may have multiple sites of upper airway obstruction (UAO). A wide variety of techniques has been used to evaluate UAO. Our aim was to compare findings of cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) in identifying UAO sites in children with persistent OSA after adenotonsillectomy (AT). Retrospective chart review. The medical records of children who underwent DISE and cine MRI were reviewed. Data pertaining to demographics, past medical history, body mass index, polysomnography, findings of DISE, and cine MRI were obtained. Fifteen children (11 boys, 4 girls; age range, 7-18 years) were identified. Comorbid conditions were Down syndrome in nine patients, cerebral palsy in one, attention deficit hyperactivity disorder in two, and asthma in three. Severity of OSA was moderate in five, and severe in 10. DISE and cine MRI showed the same UAO site in 10 patients: a single site (tongue) in nine and multiple sites (tongue and oropharynx/lateral walls) in one. DISE showed additional UAO sites undetected by cine MRI in three patients. Cine MRI showed additional UAO sites undetected by DISE in one patient. DISE and cine MRI showed different sites of obstruction in one patient. Cine MRI and DISE documented single and multiple sites of UAO in children with persistent OSA after AT. Cine MRI and DISE findings were similar in the majority of the children. Assessment of the sensitivity and specificity of cine MRI and DISE in detecting sites of UAO merits further investigation. 4. Laryngoscope, 127:1224-1230, 2017.

Adaptación y validación al español del cuestionario de calidad de vida OSA-18 para la evaluación del síndrome de apnea-hipopnea de sueño infantil

ObjectivesTo analyze the reliability and validity of the Spanish version of the OSA-18 quality of life questionnaire in children with apnea-hypopnea syndrome (SAHS). MethodChildren with suspected SAHS were studied with polysomnography (PSG) before and after adenotonsillectomy (AA). Age, gender, clinical data, PSG, anthropometric data, and Mallampati and Brodsky scales were analyzed. OSA-18 was administered at baseline and 3-6months post AA. After translation and backtranslation by bilingual professionals, the internal consistency, reliability, construct validity, concurrent validity, predictive validity and sensitivity to change of the questionnaire was assessed. ResultsIn total, 45 boys and 15 girls were evaluated, showing BMI 18±4, neck 28±5, Brodsky (0: 7%; <25%: 12%; 25-50%: 27%; >50 to <75%: 45%; >75%: 6%), AHI 12±7 pre AA. Global Cronbach alpha was 0.91. Correlations between domains were significant except for emotional aspects, although the total scores correlated with all domains (0.50 to 0.90). The factorial analysis was virtually identical to the original structure. The total scores showed good correlation for concurrent validity (0.2-0.45). With regard to predictive validity, the questionnaire adequately differentiated levels of severity according to Mallampati (ANOVA P=.002) and apnea-hypopnea index (ANOVA P=.006). Test-retest reliability was excellent, as was sensitivity to change, both in the total scores (P<.001) and in each domain (P<.001). ConclusionsThe Spanish adaptation of the OSA-18 and its psychometric characteristics suggest that the Spanish version is equivalent to the original and can be used in Spanish-speaking countries.

Immediate and Sustained Improvement in Behavior and Life Quality by Adenotonsillectomy in Children With Sleep-Disordered Breathing.

ObjectivesTo investigate longitudinal changes in behavior and quality-of-life (QoL) in children with sleep disordered breathing (SDB) after adenotonsillectomy (AT).MethodsThis study prospectively enrolled 148 children who underwent AT for SDB. Caregivers filled out Korean attention deficit hyperactivity disorder (ADHD) rating scale (K-ARS) and Korean version of the obstructive sleep apnea-18 (KOSA-18) at preoperative 1 day, postoperative 1 month, and postoperative 6 months. Longitudinal changes in K-ARS and KOSA-18 were evaluated and compared among subgroups.ResultsBoth K-ARS and KOSA-18 scores improved immediately at postoperative 1 month and were maintained at postoperative 6 months. The mean preoperative K-ARS scores of the non-ADHD, ADHD-trait, and overt-ADHD groups showed uniformly immediate and sustained improvements. Also, the mean preoperative KOSA-18 scores of the small, moderate, and large impact groups were significantly improved both at postoperative 1 month and 6 months. The changes in behavior and QoL showed no significant differences with regard to the aforementioned factors.ConclusionAfter AT, we may expect immediate and sustained improvements in behavior and QoL in children with SDB regardless of preoperative symptom severity. Moreover, by performing AT, improvements in behavior and QoL are expected regardless of sex, age, allergic trait, or concurrent coblation-assisted turbinoplasty. These findings may help our colleague physicians counselling pediatric SDB patients and their caregivers.

Adenotonsillectomy Complications: A Meta-analysis.

Complications after adenotonsillectomy (AT) in children have been extensively studied, but differences between children with and without obstructive sleep apnea (OSA) have not been systematically reported. Our objective was to identify the most frequent complications after AT, and evaluate if differences between children with and without OSA exist. Several electronic databases were searched. A partial gray literature search was undertaken by using Google Scholar. Experts were consulted to identify any missing publications. Studies assessing complications after AT in otherwise healthy children were included. One author collected the required information from the selected articles. A second author crosschecked the collected information and confirmed its accuracy. Most of the selected studies collected information from medical charts. A total of 1254 studies were initially identified. Only 23 articles remained after a 2-step selection process. The most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%). Four studies compared postoperative complications in children with and without OSA, and revealed that children with OSA have nearly 5 times more respiratory complications after AT than children without OSA (odds ratio = 4.90; 95% confidence interval: 2.38-10.10). In contrast, children with OSA are less likely to have postoperative bleeding when compared with children without OSA (odds ratio = 0.41; 95% confidence interval: 0.23-0.74). The most frequent early complications after AT are respiratory compromise and secondary hemorrhage. Based on the current limited evidence, children with OSA appear to have more respiratory complications. Conversely, hemorrhage appears to be more frequent in children without OSA.

Evaluation of body growth in prepubertal Japanese children with obstructive sleep apnea after adenotonsillectomy over a long postoperative period

ObjectiveThe aim of this study was to identify changes in body growth patterns in prepubertal Japanese children with obstructive sleep apnea (OSA) after adenotonsillectomy (AT) over a long postoperative period. MethodsWe retrospectively analyzed the hospital records of 69 children, aged 3–10 years with OSA, who were followed-up for a median period of 38 months (range, 24–92 months) after AT. Height and weight were measured during the preoperative period and 12, and 24 months postoperatively, data were converted to standard deviation scores (SDS) using current gender- and age-specific values for the growth parameters adopted by the National growth chart of Japan. Comparisons between the pre and postoperative SDS values for height and weight were performed. The numerical data were examined statistically. ResultsThe SDS for height and weight of Japanese OSA children significantly increased 24 months post AT and continued over the entire 24-month follow-up period. Height growth acceleration after AT ended earlier in children of 6.0±1.5 years at the time of AT than in children of 4.7±1.3 years who could not catch-up. ConclusionIn prepubertal Japanese children with OSA, AT was effective for the growth of those children over a long postoperative period.

Influence of Tonsillar Size on OSA Improvement in Children Undergoing Adenotonsillectomy.

To determine if pediatric obstructive sleep apnea (OSA) improves after adenotonsillectomy (AT) regardless of tonsil size. Case series with chart review. Pediatric Otolaryngology Department, Johns Hopkins Hospital. Seventy children 1 to 18 years of age who underwent polysomnography (PSG) before and after AT. Tonsil size was evaluated using the Brodsky grading scale. Children were stratified by tonsil size as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). There was a significant improvement in obstructive apnea-hypopnea index (oAHI), apnea index (AI), and saturation nadir across all 3 groups after AT. Preoperative oAHI, AI, and hypopnea index (HI) were similar regardless of tonsil size (P > .05). Overall, oAHI improved from a median of 11.8 ± 21.7 to 2.0 ± 6.1 events/h, with 40% (28/70) of children having complete resolution. The oAHI (P < .0001-0.02), AI (P < .0001-0.017), HI (P < .0001-0.058), and saturation nadir (P < .0001-0.017) significantly improved for the 2+, 3+, and 4+ groups. Only the HI (P = .058) in the 2+ group did not. The median oAHI improvement was 3.4 ± 26.4 events/h in the 2+ group, 8.3 ± 16.6 events/h in the 3+ group, and 12.3 ± 19.5 events/h in the 4+ group, with 25% (5/20), 50% (18/36), and 36% (5/14), respectively, having complete resolution. There was no correlation between OSA severity and tonsil or adenoid size (P > .32). Tonsil size did not correlate with OSA severity. While a larger proportion of patients classified as 3+ and 4+ had complete resolution after surgery, significant improvement was seen in AI and saturation nadir even in those classified as 2+.

Craniofacial contribution to residual obstructive sleep apnea after adenotonsillectomy in children: a preliminary study.

Pediatric obstructive sleep apnea (OSA) is frequently associated with adenotonsillar hypertrophy, and the fact that about 30% of affected children continue to show OSA after adenotonsillectomy (AT) suggests the presence of some other predisposing factor(s). We hypothesized that abnormal maxillofacial morphology may be a predisposing factor for residual OSA in pediatric patients. A total of 13 pediatric OSA patients (9 boys and 4 girls, age [median (interquartile range)] = 4.7 (4.0, 6.4) y, body mass index (BMI) z score = -0.3 (-0.8, 0.5)) who had undergone AT were recruited for this study. Maxillomandibular size was measured using an upright lateral cephalogram, and correlations between size and the apnea hypopnea index (AHI) values obtained before (pre AT AHI) and about 6 months after AT (post AT AHI) were analyzed. AHI decreased from 12.3 (8.9, 26.5)/h to 3.0 (1.5, 4.6)/h after AT (p < 0.05). Residual OSA was seen in 11 of the 13 patients (84.6%) and their AHI after AT was 3.1 (2.7, 4.7)/h. The mandible was smaller than the Japanese standard value, and a significant negative correlation was seen between maxillomandibular size and post AT AHI (p < 0.05). These findings suggest that the persistence of OSA after AT may be partly due to the smaller sizes of the mandible in pediatric patients. We propose that the maxillomandibular morphology should be carefully examined when a treatment plan is developed for OSA children.

Does OSA in Children with Small Tonsils Improve after Adenotonsillectomy?

Objectives: There is conflicting opinion regarding the clinical utility of removing small tonsils in children with obstructive sleep apnea (OSA). We sought to (1) determine if OSA improves after adenotonsillectomy (AT) in children with small tonsils; and (2) investigate the relationship between OSA resolution and tonsil size after AT. Methods: Retrospective study of 1- to 18-year-old consecutive nonsyndromic children with OSA who underwent polysomnography before and after AT. Complete response was defined as obstructive respiratory disturbance index (RDI) &lt; 1.5. Results: Seventy children (36 female) were included; mean age was 5.9 ± 4.3 years. Tonsils were categorized as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). Preoperative RDI, obstructive apnea index (AI), and obstructive hypopnea index (HI) were similar regardless of tonsil size ( P &gt; .05). Overall RDI improved from 18.6 ± 8.6 to 4.0 ± 6.0 with 44% (31/70) complete responders. In the 2+ group, AI and saturation nadir significantly improved ( P = .004-.033) but HI and RDI did not ( P = .08-21). All 4 parameters significantly improved for the 3+ ( P = .001-&lt;.0001) and 4+ ( P = .018-.003) groups. The mean RDI improvement in the 2+ group was 10.8 ± 5.9 events/hour with 25% (5/20) complete responders, 14.8 ± 2.4 with 56% (20/36) responders in the 3+ and 18.7 ± 5.4 with 43% (6/14) responders in the 4+ group. There was no correlation between OSA severity and tonsil or adenoid size ( P &gt; .32). Conclusions: Tonsil size did not correlate with OSA severity. While a larger proportion of patients with 3+/4+ tonsils had complete response after surgery, significant improvement was seen in AI and saturation nadir even in those with 2+ tonsils.

Periodic leg movements during sleep in children scheduled for adenotonsillectomy: frequency, persistence, and impact

ObjectiveThe aim of this study was to assess the frequency and potential clinical impact of periodic leg movements during sleep (PLMS), with or without arousals, as recorded incidentally from children before and after adenotonsillectomy (AT). MethodsChildren scheduled for AT for any clinical indications who participated in the Washtenaw County Adenotonsillectomy Cohort II were studied at enrollment and again 6 months thereafter. Assessments included laboratory-based polysomnography, a Multiple Sleep Latency Test (MSLT), parent-completed behavioral rating scales, neuropsychological testing, and psychiatric evaluation. ResultsParticipants included 144 children (81 boys) aged 3–12 years. Children generally showed mild to moderate obstructive sleep apnea (median respiratory disturbance index 4.5 (Q1 = 2.0, Q3 = 9.5)) at baseline, and 15 subjects (10%) had at least five periodic leg movements per hour of sleep (PLMI ≥ 5). After surgery, 21 (15%) of n = 137 subjects who had follow-up studies showed PLMI ≥ 5 (p = 0.0067). Improvements were noted after surgery in the respiratory disturbance index; insomnia symptoms; sleepiness symptoms; mean sleep latencies; hyperactive behavior; memory, learning, attention, and executive functioning on NEPSY assessments; and frequency of attention-deficit/hyperactivity disorder (DSM-IV criteria). However, PLMI ≥ 5 failed to show associations with worse morbidity in these domains at baseline or follow-up. New appearance of PLMI ≥ 5 after surgery failed to predict worsening of these morbidities (all p > 0.05), with only one exception (NEPSY) where the magnitude of association was nonetheless negligible. Similar findings emerged for periodic leg movements with arousals (PLMAI ≥ 1). ConclusionPLMS, with and without arousals, become more common after AT in children. However, results in this setting did not suggest substantial clinical impact.