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