Tonsil and adenoid surgery for upper airway obstruction in children.

From the Department of Otorhinolaryngology, Al-Arab Medical University, Benghazi, Libya.

Reprint requests: Ibrahim Elsherif, 96 Grangebrook Ave., Rathfarnham, Dublin 16, Ireland. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Abstract

We studied the outcomes of 76 children, aged 3 to 12 years, with large tonsils and/or large adenoids who underwent surgery to relieve upper airway obstruction over a 1-year period. Following surgery, nearly all patients experienced an alleviation of all symptoms, except for enuresis. We suggest that children who have large tonsils and/or adenoids will gain substantial benefit if they are removed, even children who do not have a history of severe sleep apnea or objective evidence from polysomnography.

Introduction

Most upper airway obstruction in children is caused by adenotonsillar hypertrophy. Obstructive sleep apnea caused by adenotonsillar hypertrophy is a definite indication for surgery. [1-4] Hypopnea can occur when airflow is impaired but not completely obstructed. [5] Among children, clinically significant obstructive hypopnea with partial upper airway obstruction is more common than obstructive sleep apnea with complete obstruction.[5-8] Using adult criteria to detect obstructive sleep apnea--that is, the hourly number of apneic events with complete airway obstruction--will not identify most children who have serious upper airway obstruction during sleep. [8,9] There are many other 0causes of upper airway obstruction and consequent sleep apnea in children, including nasal obstruction, micrognathia, generalized facial anomalies, laryngeal disorders, and neuromuscular problems. [10]

Prolonged partial airway obstruction during sleep may result in significant hypercapnia and hypoxemia, as well as daytime somnolence, night sweats, irritability, hyperactivity, behavioral problems, personality changes, poor school performance, morning headache, failure to thrive, obesity, and enuresis.[11-19] The airway obstruction in such children may be exacerbated by upper respiratory tract infection to the degree that the situation may become life-threatening.20 Cor pulmonale develops in some children because of vasoconstriction in pulmonary blood vessels as a result of frequent episodes of hypoxemia during recurrent apnea. Only a small percentage of susceptible children with severe upper airway obstruction go on to develop pulmonary hypertension. [16,21]

Children with sleep apnea virtually always snore loudly. Episodes of snoring are interrupted by periods of silence, which terminate in a loud snort. Recent reports suggest that snoring may occur in the normal child. Teculescu et al reported that 10% of French preschool children between the ages of 4 and 6 years were habitual snorers. [22] In an Italian study, Corbo et al found that approximately 7% of children between the ages of 6 and 11 years were snorers. [23] In a British study, Owen and colleagues reported that 27% of children younger than 10 years snored on regular basis; the incidence rose to 47% in the presence of an upper respiratory tract infection. [24]

In clinical practice, there is a wide spectrum of symptomatic severity, and many children will not fulfill the strict diagnostic criteria for the "sleep apnea syndrome." These children may still have a considerable degree of morbidity that can be dramatically improved by alleviating their upper airway obstruction.

The aim of this article is to review the main complaints of children who have marked upper airway obstruction caused by large tonsils and/or adenoids, and to document the effect of surgery.

Materials and methods

We selected for study 76 patients (38 boys and 38 girls) from a total of 1,124 children who had undergone tonsillectomy and/or adenoidectomy between January and December 1994 at the Hawari Hospital in Benghazi, Libya. These children were selected because their upper airway obstruction was the result of either tonsils or large adenoids. The children ranged in age from 3 to 12 years; most (63%) were between 5 and 10 years of age.

Most of these children had been referred for the treatment of snoring or noisy breathing and recurrent sore throat. The children were otherwise healthy, and none was obese. A total of 52 children underwent adenoton sillectomy, while the other 24 had only an adenoidectomy.

Parents were interviewed with the aid of a questionnaire before and 6 weeks after surgery. Prior to surgery, each child was examined and investigated thoroughly. All children were admitted 1 day before surgery. The operations were performed by the same surgical team. Most of the children were discharged the following day.

Results

Almost all of the children experienced a resolution of their symptoms (table). In addition, surgery also improved the general overall well-being of 86% of them. Nearly two-thirds reported improvement in their schoolwork.

Mouth-breathing and noisily breathing children took approximately 2 to 3 weeks to improve. Children who had complained of choking experienced a gradual decline in the frequency of these episodes. The only symptom that was not alleviated by surgery in our series was enuresis; only 2 of the 11 children (18%) who were bed-wetters showed any improvement.

Discussion

The results of this study illustrate that the obstructive symptoms due to large tonsils and/or adenoids are eminently treatable by surgery, and this finding is concordant with those of other studies. [13,20,24] Although snoring and noisy breathing during sleep were usually described clearly by the parents, eliciting a history of sleep apnea often required direct questioning, explanation, and prompting. Sleep apnea may persist after surgery, but these episodes are likely to represent central apnea, and they are likely to be fewer in number. [25]

The symptomatic relief of obstruction following adenoidectomy and/or tonsillectomy has been documented by others, and although the numbers of patients in these reports were small, the results were consistently good. [5,13,17,20,26-32] In those children whose respiration was monitored, breathing irregularities were less common and apneic episodes were fewer and shorter after surgery. [13,17] It has been suggested that in patients with upper airway obstruction, polysomnography is desirable to facilitate a more precise prediction of the outcome of a specific treatment. [27]

The results of our study were excellent. We suggest that for those children who have breathing difficulties that are thought to be caused by large adenoids and/or tonsils, surgery should not be withheld or delayed solely because of a lack of objective evidence. In fact, symptomatic relief can be anticipated with some degree of confidence. Most of the symptoms are reversible after relief of the upper airway obstruction by tonsillectomy and/or adenoidectomy. [2,32,33] Alleviation of mouth breathing, behavioral problems, enuresis, poor appetite, right ventricular strain, and poor concentration have been documented following adenotonsillectomy. [5,7,34-36] Ahlqvist-Rastad and colleagues reported that "in many families, the psychosocial situation improved greatly after surgery. Disturbed sleep was a problem also for the parents who often did not dare to sleep themselves in order to cope with their child's apnea." [37] Adenotonsillar hypertrophy with upper airway obstruction, even without frank obstructive sleep a pnea, is an indication for tonsillectomy or adenoidectomy. [1,2,4]

Prolonged upper airway obstruction is known to cause right ventricular hypertrophy in some children. In a prospective study of 92 children who were admitted for adenotonsillectomy in England, three had evidence of right heart strain in addition to apnea, snoring, and daytime somnolence. [17] Death during anesthesia has been reported in children with sleep apnea, and may be precipitated by hypoventilation during induction in children with right heart strain. [34] It is therefore critical to exclude or identify such cardiac abnormalities prior to surgery. Children of any age who have warning signs of potential postoperative respiratory problems should be kept for overnight observation and respiratory monitoring postoperatively. [38]

In conclusion, the hallmark of upper airway obstruction in children is snoring, and this should prompt further investigation regarding other sleep-related symptoms. In children who have large tonsils and/or adenoids, substantial benefit may be attained by removing the offending lymphoid tissue, even though the child may not have a history of severe sleep apnea and even though objective evidence from polysomnography may be lacking. Study results serve to stress that generations of ENT surgeons have been quite justified in recommending adenoidectomy and/or tonsillectomy for the treatment of pediatric upper airway obstruction that is thought to be brought on by adenotonsillar hypertrophy. With proper case selection, much is to be gained from such surgery.

References

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           The prevalence of symptoms in 76 children with upper
         airway obstruction before and after tonsillectomy and/or
                               adenoidectomy

                            Before   After  Success
                            surgery surgery  rate
Symptoms                      (n)     (n)     (%)
Nocturnal symptoms
 Snoring                      65       3      95%
 Restlessness                 58       0     100%
 Mouth breathing              53       2      96%
 Noisy breathing              42       2      95%
 Sleep apnea                  22       0     100%
 Choking                      15       0     100%
 Enuresis                     11       9      18%
 Cyanosis                     10       0     100%
Daytime symptoms
 Sleepiness                   49       0     100%
 Noisy eating                 45       0     100%
Miscellaneous
 Improved general condition           65      86%
 Improved study performance           50      66%
 Improved appetite                    45      59%