Cases in Tonsil Disease: From the Routine to the Serious

Gordon H. Sun, MD, MS

Disclosures

May 23, 2017

Sleeping, Breathing, and Tonsils

For most children, PSG is not indicated before tonsillectomy. The AAO-HNSF clinical practice guideline on PSG for SDB prior to tonsillectomy in children describes several situations in which preoperative PSG is helpful, including obesity, Down syndrome, neuromuscular or craniofacial disorders, mucopolysaccharidoses, and sickle cell disease, as well as cases in which the need for surgery is uncertain or when there is discordance between tonsillar size and reported SDB severity.[24] SDB, a spectrum of sleep disorders ranging from snoring to obstructive sleep apnea (OSA), is particularly common among obese and overweight children. The prevalence of OSA is 1%-6% in the general pediatric population and 13%-61% in obese children and adolescents.[25,26] Patients with obesity and SDB have more than sevenfold higher risk for postoperative respiratory complications.[27]

The impact of tonsillectomy on the resolution of SDB-related symptoms is dependent on whether the patient is overweight or obese. SDB resolves in 70%-80% of children of normal weight.[28] However, tonsillectomy is rarely curative among children with obesity, with only a 10%-25% success rate.[29] Although the average apnea-hypopnea index drops nearly 65% after adenotonsillectomy in children with obesity, fewer than half of these patients have a postoperative apnea-hypopnea index <5.[29] Such patients may require additional interventions such as continuous positive airway pressure or uvulopalatopharyngoplasty.[30,31]

Nocturnal enuresis is a common pediatric health-related issue. Up to half of children with SDB also present with enuresis.[20] A 2012 systematic review found that the prevalence of enuresis in children with SDB declined significantly from 31% preoperatively to 16% postoperatively.[32]

The QOL of children with SDB who undergo tonsillectomy is higher than that of children who are managed with watchful waiting. The CHAT trial[33] randomly assigned 464 children with OSA to either early adenotonsillectomy or observation. The early surgery group had a larger proportion of normalization of PSG findings and greater reduction of symptoms and improvement of QOL and behavioral outcomes at 7-month follow-up, but they showed no significant improvement in attention or executive function based on neuropsychological testing. A follow-up study confirmed significant improvements in QOL and symptoms regardless of weight and baseline OSA severity. Race attenuated the relative benefit of surgery on the total score and behavior subscale of the Sleep-Related Breathing Disorder of the Pediatric Sleep Questionnaire but otherwise had no impact on other QOL or symptomatic outcomes.[34] A 2015 Cochrane review[35] concluded that healthy, nonsyndromic children between 5 and 9 years of age and diagnosed with mild-to-moderate OSA by PSG gain benefit in terms of QOL, symptoms, behavior, and PSG parameters after adenotonsillectomy. The review also noted that at 7 months, half of nonsurgically treated children had normalization of PSG parameters, suggesting that watchful waiting is a reasonable option. Many patients will recover spontaneously with sufficient time.[35]

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