Obstructive Sleep Apnea Tonsillectomy and Adenoidectomy in Pediatric Patients

Obstructive Sleep Apnea
Tonsillectomy and
Adenoidectomy in Pediatric
Patients
Eyal Russo M.D.
E.N.T. Department
E. Wolfson Medical Center, Holon
Introduction

1994 140,000 U.S. children under the age
of 15 had adenoidectomies and 286,000
had adenotonsillectomies

This is down from a peak of over 1 million
in the 1970’s

These are the most common major
surgical procedures in children.
History

Celsus first described tonsillectomy in 30 A.D.

Paul of Aegina wrote his description in 625 A.D.

1867 Wilhelm Meyer reports removal of “adenoid
vegetations” through the nose with a ring knife.

1917 Samuel J. Crowe published his report on
1000 tonsillectomies, used Crowe-Davis mouth
gag

Part of Waldeyer’s ring after the German
anatomist who described them
Anatomy of the adenoids

Single pyramidal mass of tissue based on
posterior-superior nasopharynx
 Surface folded without true crypts
 Blood supply – ascending palatine branch of
facial artery, ascending pharyngeal artery,
pharyngeal branch of internal maxillary
artery
 Innervation – glossopharyngeal and vagus
 No afferent lymphatics, efferents drain to
retropharyngeal and upper deep cervical
nodes
Anatomy of the Tonsils

Paired, sit in tonsillar sinus
 Limited anteriorly by palatoglossal arch,
posteriorly by palatopharyngeal arch,
laterally by superior pharyngeal constrictor
 Enclosed in a fibrous capsule
 Blood supply from tonsillar and ascending
palatine branches of facial artery, ascending
pharyngeal artery, dorsal lingual branch of
the lingual artery and the palatine branch of
maxillary artery
Adenotonsillar disease

Major divisions are:
– Infection/inflammation
– Obstructive
– Neoplasm
Obstructive Adenoid Hyperplasia

Signs and Symptoms
–
–
–
–
Triad of:
Obligate mouth breathing
Hyponasal voice
Snoring and other signs
of sleep disturbance

Rhinorrhea, nocturnal
cough, post nasal drip
 Overbite, long face,
crowded incisors
“Adenoid facies”
Obstructive Tonsillar
Hyperplasia

Snoring and other symptoms of sleep
disturbance

Muffled voice

Dysphagia
Adenoidectomy

Current clinical indicators from AAO-HNS:
– 4 or more episodes of recurrent purulent rhinorrhea
in prior 12 months in a child <12. One episode
documented by intranasal examination or diagnostic
imaging.
– Persisting symptoms of adenoiditis after 2 courses of
antibiotic therapy. One course of antibiotics should be
with a beta-lactamase stable antibiotic for at least 2
weeks.
– Sleep disturbance with nasal airway obstruction
persisting for at least 3 months
– Hyponasal or hypernasal speech
– Otitis media with effusion >3 months or second
set of tubes
– Dental malocclusion or orofacial growth
disturbance documented by orthodontist
– Cardiopulmonary complications including cor
pulmonale, pulmonary hypertension, right
ventricular hypertrophy associated with upper
airway obstruction
– Otitis media with effusion over age 4
Tonsillectomy

Current clinical indicators of AAO-HNS:
– 3 or more infections per year despite adequate
medical therapy
– Hypertrophy causing dental malocclusion or
adversely affecting orofacial growth documented
by orthodontist
– Hypertrophy causing upper airway obstruction,
severe dysphagia, sleep disorder, cardiopulmonary
complications
– Peritonsillar abscess unresponsive to medical
management and drainage documented by
surgeon, unless surgery performed during acute
stage
– Persistent foul taste or breath due to chronic
tonsillitis not responsive to medical therapy
– Chronic or recurrent tonsillitis associated with
streptococcal carrier state and not responding to
beta-lactamase resistant antibiotics
– Unilateral tonsil hypertrophy presumed neoplastic
Pediatric OSAS

Rising indication for adenotonsillectomy

Many features are different

2% of children

Males = Females

Peak at age 2-5

Peak OSA = Peak ATH

Snoring – severity not predictive

Many are mouth breathers
– Adenoid facies (15% have OSAS)

Excessive daytime sleepiness

Obesity vs. FTT
Pediatric OSAS

Parasomnias
 Restless sleep
 Aggressive behavior
 Hyperactivity
 Developmental delay
 ADD
 Learning disabilities
 Enuresis
Pediatric OSAS

Impaired growth
– Possible impairment of release or end-organ
response to GH
– Increased caloric effort with respiration
– Difficulty with eating

Cor pulmonale

Associated with GERD
Diagnosis

History *

Physical exam *

The child who always snores, has restless
sleep secondary to obstruction, & has
apneic episodes per the parents virtually
always has PSG confirmation (Brouillette)
Polysomnogram

Obstructive apnea – cessation of airflow for
at least 10 seconds with respiratory effort

Central apnea – cessation of airflow for at
least 10 seconds without respiratory effort

Mixed apnea – characteristics of both for at
least 10 seconds

Hypopnea – hypoventilation secondary to
partial obstruction
Polysomnogram

Apnea index
 Apnea-Hypopnea index = respiratory
disturbance index
 Arousal index
Polysomnogram
Polysomnogram

parameters for abnormal results are not
standardized in children RDI > 1 or 5

Not cost effective, expensive

Considerations
– CNS disease
– Age < 2
– Increased surgical risks
– Family desires
– Discordant exam, questionable cases
– Persistent obstructive symptoms after T&A
Polysomnogram

American Academy of Pediatrics guideline
for diagnosis of patients with OSAS:
1) All children should be screened for snoring
2) Complex high-risk pt. Should be referred to
a specialist
3) Pt. with cardiorespiratory failure cannot
await elective evaluation.
4) Primary snoring or OSAS – gold standard
Polysomnography
Lack of pediatric sleep labs.- difficult to follow
PreOp Evaluation of Adenoid
Disease
Evaluate palate

SCP, Symptoms of VPI
 Midline diastasis of muscles
 CNS or neuromuscular disease
 Preexisting
speech
disorder?
Bifid uvula

PreOp Evaluation of Adenoid
Disease
Lateral neck films are useful
only when history and physical
exam are not in agreement.
 Accuracy of lateral neck films
dependent on proper positioning
and pat. cooperation
 Superior is F.O.
Nasopharyngoscopy
PreOp Evaluation of Tonsillar
Disease
TONSIL SIZE

0 in fossa
 +1 <25% occupation
of oropharynx
 +2 25-50%
 +3 50-75%
 +4 >75%
Avoid gagging the patient
Down Syndrome

OSAS = 54-100%
 Physical factors
–
–
–
–
–
–

Small midface and cranium
Narrow nasopharynx
Large tongue
Muscular hypotonia
Obesity
Small larynx
Congenital heart disease / cor pulmonale
 UPPP
Tonsillectomy techniques

Tonsillectomy
– Tonsillotome
– Cold dissection (scissors, knife)
– Monopolar/bipolar electrocautery
– Harmonic scalpel
– Plasma-mediated ablation=Coablation
Treatment

There is a little debate that the primary
treatment for most children with OSAS
is T&A
Complications
#1 Postoperative bleeding

incidence ranging from 0.1% to 8.1%

Incidence of mortality reported between 1
in 16,000 and 1 in 35,000 cases

Anesthetic complications and hemorrhage
cause majority of deaths

Fever, Dehydration
 Sore throat, otalgia, uvular swelling


Respiratory compromise
Velopharyngeal insufficiency
 Dental injury
 Burns
 Nasopharyngeal stenosis, E-T injury
 Atlantoaxial subluxation with Down’s
syndrome or Grisel’s syndrome(vertebral
body decalcification and anterior
transverse ligament laxity from
infection/inflammation)

Occasionally patients with:
- Obesity
- Neuromuscular disorders (CP)
- Craniofacial disorders
- Severe OSAS
Respiratory difficulties in the immediate
Post operative period.
 Frequently have residual OSAS after T&A
 Managed in the PICU with CPAP or
BIPAP
Indications for Observation








Age <3
Obstructive sleep apnea
Significant associated medical problems
Neurological delay
Craniofacial abnormalities
Living a long distance from the hospital
Questionable caregiver at home
Known coagulopathy
Case Study

A 3 yo boy presents to your office whose
parents complain that he snores loudly
and stops breathing sometimes while
sleeping. The child’s pediatrician told the
parents that his tonsils were “big” and
that the child is under weight for his age

Also has dysphagia and daytime
somnolence
 Apneic spells last >10 seconds
 PMH: otherwise healthy
 Meds:none
 No allergies

PE:
– Dark circles under eyes
– Breathing with mouth open
– Small amount of clear rhinorrhea
– Tonsils are almost touching in the midline

Adenotonsillar hypertrophy
 Sleep disturbance