Neuropsychological Functioning after Adenotonsillectomy in Children with Obstructive Sleep Apnea:A Meta-analysis

The present study aimed to investigate the efficacy of adenotonsillectomy(AT) for children with obstructive sleep apnea syndrome(OSAS) and the improvement of their cognitive function. Studies on cognitive performance of OSAS children treated with or without AT were identified by searching the Pubmed, EMBASE and Cochrane library. A meta-analysis was conducted to analyze the literature. The random-effects model was used to evaluate 11 eligible studies using an inverse-variance method. The neuropsychological test results of 4 cognitive domains(general intelligence, memory, attention-executive function and verbal ability) were obtained and analyzed. By comparison of cognitive function between OSAS children and healthy controls, the effect sizes of each domain were achieved as follows: general intelligence, –0.5(P<0.0001); memory, –0.18(P=0.02); attention-executive function, –0.21(P=0.002); and verbal ability, –0.48(P=0.0006). The effect sizes of general intelligence, memory, attention-executive function, and verbal ability after AT compared to baseline level were –0.37(P=0.008), –0.36(P=0.0005), –0.02(P=0.88), and –0.45(P=0.009), respectively. Comparing the cognitive ability between OSAS children after AT and healthy controls showed that the effect sizes were –0.54(P=0.0009), –0.24(P=0.12), –0.17(P=0.35), and –0.45(P=0.009) in general intelligence, memory, attention-executive function, and verbal ability, respectively. Our results confirmed that OSAS children performed worse than healthy children in terms of the 4 cognitive domains investigated. After 6–12 months of observation, significant improvement in attention-executive function and verbal ability were found in OSAS children treated with AT compared to their baseline level; restoration of attention-executive function and memory were observed in OSAS children after AT in comparison to healthy controls. Further rigorous randomized controlled trials should be conducted to obtain definitive conclusions.

Measurement of Blood Loss during Adenotonsillectomy in Children and Factors Affecting It

This prospective study was done at the Southern Railway Headquarters Hospital, Ayanavaram, Chennai to measure the intraoperative blood loss during adenotonsillectomy and to assess the factors affecting it. Since blood volume in children is low, even a small loss will result in dreaded complications, so blood loss measurement in paediatric surgery is important. Adenotonsillectomy is the most common surgery performed in the field of otolaryngology, so blood loss measurement is essential in this surgery. In the study, 50 children who underwent adenotonsillectomy, by conventional dissection and snare method for tonsillectomy and curette method for adenoidectomy, were evaluated for operative blood loss. This study was conducted over a 1 year period, from June 2013 to June 2014. Both gravimetric method and blood volume studies were used to measure the operative blood loss. The estimated blood loss by gravimetric method was 94.35 ml, whereas the actual blood loss by blood volume studies was 90.57 ml and the average blood loss was 92.46 ml. The youngest child who was operated was 4 years old and the oldest child was 15 years old. The minimum blood loss was 40.30 ml and the maximum was 278.46 ml. In our series, operative blood loss was dependent on fibrosis of tonsil and the grade of the tonsil. There was no significant correlation between age and sex of the patient and the surgical skills.

Prevalence of Symptoms of Obstructive Sleep Apnoea in Children Undergoing Routine Adenotonsillectomy

Introduction: Obstructive sleep apnoea (OSA) is a condition characterized by episodic partial or complete obstruction of the upper airway during sleep leading to apnoea or cessation of breathing. Obstruction of the upper airway during sleep may result in the generation of noise (snoring), reduction (hypopnoea) or cessation (apnoea) of airflow at the nostrils and mouth. There are multiple indications for undertaking a patient for adenoidectomy and/or tonsillectomy with obstructive sleep apnoea (OSA) being one among many. Objective: The aim of the present study was to find the prevalence of OSA symptoms in children undergoing adenotonsillectomy for indications other than that of obstructive sleep apnoea. Material & Methods: The study was conducted in the Department of ENT and Head & Neck surgery, Gauhati Medical College & Hospital, Guwahati for a period of one year. Twenty six patients who underwent adenoidectomy and/or tonsillectomy during this period were selected for the study. The parents of the patients were administered the Paediatric Sleep Questionnaire pre-operatively and the patients were evaluated for any symptoms of OSA. A score of 8 or more was suggestive of presence of breathing related sleep disorder. All statistical analyses were performed using statistical software SPSS 16.0 version. To test for the difference in the proportion between different variables, chisquare/fisher exact test where appropriate were employed. All statistical tests were two tailed with 0.05 as the threshold level of significance. Results: 11 children (42.3%) had a score of 8 or more out of the 26 children in Paediatric sleep questionnaire. The chi square for this was 4.696 with a p value of 0.096. The snoring subscale was found to be positive in 19 children (73.1%). All children with score of 8 or more were positive for the snoring scale. The sleepiness subscale was found to be positive in 14 children (53.8%). 10 of the 11 children were positive for sleepiness scale among the children who had a score of 8 or more in the questionnaire. These were found to be statistically significant. Conclusion: A significant population of the children undergoing routine adenotonsillectomy also has symptoms of obstructive sleep apnoea. The pathophysiology of obstructive sleep apnoea should be borne in mind in all children having adenotonsillar hypertrophy and a prompt and early intervention into these children should be aimed for both the infective etiology and the possible outcomes of their compromise to the airway column for a better quality of life.

A Rare Complication:Perioral Burn Related to Electrocautery Use during Adenotonsillectomy

Electrocautery is frequently used for incisions and bleeding control during adenotonsillectomy which is one of the most commonly performed pediatric surgical procedures. Although cases of perioral burn related to electrocautery use are rarely reported complications in literature, they account for a significant portion of malpractice lawsuits. The use of insulated surgical tools and lip protective equipment, careful surgery, and the frequent control of surgical equipment may decrease the number of this complication. This study examines whether a rarely reported complication related to perioral burn is indeed rarely seen or whether there are problems in reporting the real rates because it is evaluated to be a case of malpractice, and the protective factors that will prevent this problem. Consequently, it is underlined that this complication, which is more frequently seen than it is reported, should be a part of preoperative information process and the consent form.

Update on the safety of anesthesia in young children presenting for adenotonsillectomy

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children.Although a common procedure,it is not without significant risk.It is critical for anesthesiologists to consider preoperative,intraoperative,and postoperative patient factors and events to optimize safety,especially in young children.In the majority of cases,the indication for adenotonsillectomy in young children is obstructive breathing.Preoperative evaluation for patient comorbidities,especially obstructive sleep apnea,risk factors for a difficult airway,and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan.Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage.Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity.In young children,it is important to also consider the impact of anesthetic medications on the developing brain.This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients’families.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives:To examine the volume,topics,and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.Data Sources:PubMed(National Library of Medicine and National Institutes of Health),Scopus(Elsevier),CINAHL(EBSCO),and Cochrane Library(Wiley).Methods:A systematic search of four databases was conducted.Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included.Data collected included demographics,pain-related outcomes,sedation scores,nausea/vomiting,postoperative bleeding,types of drug comparisons,modes of administration,timing of administration,and identities of the investigated drugs.Results:One hundred and eighty-nine studies were included for analysis.Most studies included validated pain scales,with the majority using visual-assisted scales(49.21%).Fewer studies examined pain beyond 24 h postoperation(24.87%),and few studies included a validated sedation scale(12.17%).Studies have compared several different dimensions of pharmacologic treatment,including different drugs,timing of administration,modes of administration,and dosages.Only 23(12.17%)studies examined medications administered postoperatively,and only 29(15.34%)studies examined oral medications.Acetaminophen only had four self-comparisons.Conclusion:Our work provides the first scoping review of pain and pediatric tonsillectomy.With drug safety profiles considered,the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy.Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain.The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses.Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

Adenotonsillectomy in high risk patients: Hematologic abnormalities and COVID-19 considerations

Adenotonsillectomy is one of the most common surgical procedures performed by otolaryngologists.It is vital that surgeons are aware of the risks in performing this surgery especially during the COVID-19 pandemic and in children with hematologic disorders.In this review we describe common hematologic disorders often noted in pediatric patients undergoing this procedure,as well as proper screening and management of these patients.In addition,we also address the impact of the COVID-19 pandemic and some measures to help mitigate the risks of this procedure during this time.

Coblation Intracapsular Tonsillectomy and Coblation Complete Tonsillectomy for Obstructive Sleep Apnea

Objective: Total tonsillectomy and intracapsular tonsillectomy are common procedures for the treatment of obstructive sleep apnea (OSA) in children. The objective of this study was to compare the effectiveness of coblation intracapsular tonsillectomy (ICT) and coblation complete tonsillectomy (CT) as treatments for OSA. Study design: A retrospective study of all the children ages 2 - 18 years with OSA who underwent coblation intracapsular tonsillectomy (ICT) or coblation complete tonsillectomy (CT) from January 2007 to August 2010 by the same surgeons at one institution. Methods: Data were retrieved from children’s charts and from telephone interviews with children’s parents, regarding pre and postoperative OSA-18 scores, postoperative pain, postoperative complications, use of analgesic drugs, and time to return to a solid food diet. Results: All 43 children who underwent ICT and 37 children who underwent CT suffered from OSA before surgery, and none did postoperatively. There were no minor complications in the ICT group, compared to 13.5% in the CT group (p = 0.01). According to parental report, 72% and 21% suffered a low level of postoperative pain, and 9% and 33% severe pain in the ICT and CT groups, respectively. For these respective groups, 49% and 73% needed analgesic drugs (p < 0.05);and 65% and 35% ate solid food during the first 3 days post surgery. Conclusions: Both ICT and CT were safe, with few complications;however recovery was faster in the ICT group, as demonstrated by less pain, and more rapid return to a solid food diet.

Pattern of Paediatric Adenoid and Tonsillar Surgery in Ekiti

Background: Surgeries of adenoid, tonsils or both are common pediatric performed by otorhinolaryngologist, head, and neck surgeon worldwide. Clinical pattern and management varied in a different center. This study aimed at determining the rate, socio-demographic features, indications, barriers, types, complications and patients’ satisfaction with adenoid and tonsils surgery in low-income countries. Materials and Methods: This is a hospital-based retrospective study of pediatric patients who had adenotonsillectomy, adenoidectomy, and tonsillectomy in the study center. This study was carried out over a period of ten years from March 2007 to February 2017. Data for this study was obtained from the medical record department, ENT clinic operation booking register and theatre operation register. All the data obtained were statistically analyzed using SPSS version 16. The data were then expressed by descriptive statistics table, bar charts, and pie charts. Ethical clearance was sought for and obtained from the ethical committee of the institution. Results: A total of 463 patients were booked for adenoid and tonsillar surgery out of which 214 patients had surgery done during the study period. This represented 46.2% of the participants that had surgery done. Adenotonsillectomy peaked 38.3% at preschool age group: (1 - 5) years. There were 58.9% males and male to female ratio was 1.5:1. Majority 42.5% of the patients reside in the city while minority 25.7% of the patients were village dwellers. Preschool ages were the majority 40.2% while post-secondary schools ages were the minority 8.4% of the patients. The parents of the majority of the patients were 27.1% health workers and 24.8% business men, while the parent of the minority of the patients was 11.7% farmers and 16.4% industrial workers. Major indications for surgery were 52.3% obstructive sleep apnoea syndrome and 21.5% recurrent tonsillitis. Less common indications for surgery in this study were 1.4% persistent fever and 1.9% cardiopulmonary complications. There were 7.0% patients admitted as day cases and 93.0% patients admitted as an in-patient. Postoperatively, 1.4% of the day cases were admitted as inpatients while 1.9% of inpatients were treated as day cases. In this study, the established high risk factors include age less than 1 year 13.6%, Down syndrome 1.4%, craniofacial abnormalities 1.9%, malnutrition 10.7%, serum electrolyte and urea imbalance 10.3%, cardiovascular disease 3.7%, respiratory disease 7.5%, anaemia 8.9%, haemoglobinopathy 3.3% and coagulopathy 1.9%. There were no specific comorbidities that may likely influence the surgical outcome in majority 70.6% of the patients. Adenotonsillectomy was performed on 43.9% patients. Adenoidectomy only was performed on 24.8% patients. The proportion of adenoidectomy alone performed among the age group was 19.2% and 0.5% forages (1 - 5) and (16 - 18) years respectively. Conclusion: Adenoid and tonsils surgery are common pediatric otorhinolaryngologist surgical procedures faced with a different form of surgical barriers in low-income countries. These procedures were faced with a various form of risks and the cause of death in this study was cardiopulmonary complications.

The Association between Preoperative Parental Anxiety and Emergence Agitation in Preschoolers

Introduction: The preoperative distress and anxiety experienced by preschoolers are associated with an increased incidence of troubled recovery from anesthesia. However, influences of parental anxiety on children at different stages of the surgical processes are not clear. The aim of this study was to evaluate any existing association between preoperative parental anxiety and emergence agitation in a pediatric surgery population. Materials and Methods: A total of 60 children ASA class I or II, aged 3 - 12 years old, undergoing adenotonsillectomy with sevoflurane, were included in the study. Before surgery, we used State-Trait Anxiety Inventory S-T (STAI S-T) to assess parental anxiety. Emergence agitation of the children was assessed with Watcha scale and recorded every 10 min of first 30 min of the postoperative period. Parents were contacted 24 hours after the surgery to evaluate their satisfaction, post operative pain and any side effect observed in the children. Results: Preoperatively, the mean STAI-S scores of mothers were significantly higher than those of fathers (p 0.05). The children had the highest agitation scores at 10th postoperative minutes with an incidence of 73.9%. There was no correlation between parental anxiety and emergence agitation. Logistic regression analysis showed that low educational level of the parent was the only independent factor for state anxiety (OR: 8.96, 95% CI: 1.50 - 40.35, p = 0.030). Discussion: In this study, we observed that education level of the parents might affect their preoperative anxiety. The factors influential in parental anxiety were not correlated with pediatric emergence agitation in this study.

Pediatric drug-induced sleep endoscopy: An updated review of the literature

The field of drug-induced sleep endoscopy(DISE)has grown considerably over the last 10~15 years,to now include its use in pediatric patients.In this review article,we outline our approach to the use of this technology in Children with Airway Obstruction,most specifically in the management of children with airway obstruction and known or suspected adenotonsillar enlargement.

Alternatives to surgery in children with mild OSA

Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient.In this context,the treatment approach to mild obstructive sleep apnea(OSA)is fraught with substantial debate as to what is mild OSA,and as to what constitutes appropriate treatment.As such,it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA,and then examine the circumstances under which treatment is indicated,and if so,whether and when anti-inflammatory therapy(AIT),rapid maxillary expansion(RME),and/or myofunctional therapy(MFT)may be indicated.

Updates on management of pediatric obstructive sleep apnea

Obstructive sleep apnea(OSA)affects about 1%-5%of the pediatric population.The consequences of untreated OSA in children include neurocognitive deficits,behavioral problems,poor school performance as well as systemic and pulmonary hypertension.The treatment options for pediatric OSA are numerous with a variety of surgical and non-surgical interventions.As our understanding of the complexities of OSA grows,the options for management have continued to expand as well.The objectives of this review are to describe the commonly prescribed treatments for pediatric OSA including adenotonsillectomy as well as use of positive airway pressure.We also highlight other surgical and non-surgical interventions available.In addition,we provide updates on current research focusing on newer diagnostic and experimental treatment modalities.