Galioto GB (ed): Tonsils: A Clinically Oriented Update. Adv Otorhinolaryngol. Basel, Karger, 1992, vol 47, pp 271-275
Obstructive Sleep Apnea Syndrome and A&T Surgery M . De Benedetto, D. Cuda, M. Leante ORL Department, S. Caterina Novella Hospital, Gaiatina, Leece, Italy
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Obstructive sleep apnea syndrome (OSAS) can occur frequently in children with adenoid and tonsillar hypertrophy (A TH) [1-3]. It is well known that A&T surgery is a very effective treatment when obstructive symptoms are unequivocally attributable to ATH, affording complete relief [4-6]. For these reasons, OSAS represents a definite indication for A&T operation [4, 5]. OSAS is a disease potentially severe in children and it is characterized by a wide range of symptoms: sleep disturbances, diurnal manifestations (behavioral disturbance, excessive daytime somnolence) and in some cases severe cardiopulmonary sequelae [7-13]. It appears likely that OSAS may be more common than it is generally appreciated. The identification of children affected by OSAS is a difficult task because of poor knowledge of epidemiology and the difficulties in the diagnosis of disease. We consider three different levels of diagnostic definition of OSAS: 'suspect', 'likely' and 'definite'. 'Definite OSAS' is a diagnosis based on polysomnographic recordings. However, the poor availability of sleep laboratories, the costs and the possible nonacceptance preclude a large use of polysomnography in the pediatric population. 'Likely OSAS' is based on a simplified test that monitors tissular O 2 saturation during sleep. The evidence of several phasic drops in 02 saturation is strongly suggestive of OSAS in children with ATH [14]. Several clinical oximeters are now available and regular usage is also possible at the child's home. 'Suspect OSAS' is based on clinical data such as habitual snoring and/or direct parental observation of apneas during sleep in a child with significant ATH.
De Benedetto/CudalLeante
272
In order to quantify the problem of OS AS in relation to A&T surgery, in this paper we refer epidemiological data of 'suspect OSAS' and 'likely OSAS' in some clinical pediatric populations. We refer also about current A&T surgical trends at our Department.
'Suspect' OSAS A questionnaire concerning sleep disturbances and related problems was submitted to parents of 307 children aged 0-10 years (mean 4.7, SD 2.4) referred consecutively to their pediatrician for various clinical problems. 141 were girls and 166 were boys. In 101 cases (32.9%) snoring was referred to as occasional ('sometimes' or 'often') or habitual ('always'). Habitual snoring was described in only 17 cases (5.5%). Sleep apnea was referred to in 6.9% of cases. It is important to remember, however, that an answer to this question was difficult to obtain in 17.3% of cases due to the parents' lack of awareness about this sleep disorder. Significant ATH was mentioned by pediatricians in 30.2 % of the cases in question. Percentage data concerning the total prevalence of snoring and prevalence of habitual snoring alone, of apnea and of ATH per age groups, are shown in table 1; the close link between ATH and snoring is also emphasized. They present an overlapping age trend and similar prevalence. Prevalence reaches its peak between 5 and 7 years of age. Despite a few discrepancies in the upper age groups probably due to the low number of patients, habitual snoring and apnea also show a similar trend. In summary, from the gathered data we can conclude that about 30% of the children of the general pediatric practice have ATH strictly correlated to some sort of snoring. Cases with major obstruction (habitual snoring and apnea) were pinpointed in 5-7 % with a maximum peak at the age of 5-7 years. These data are in accord with Corbo et al. [15], who report a mean prevalence of habitual snorers of 7.3% in a large sample of children aged 6-13 years.
As an indicator of the likely presence of OSAS in children, we recorded O 2 tissular saturation during sleep with a transcutaneous electrode in 36 children (average age 4.6, SD 2.6) with obstructive and/or
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
'Likely' OSAS
273
Obstructive Sleep Apnea Syndrome and A&T Surgery
Table 1. Prevalence of snoring, apnea and A&T hypertrophy in a pediatric sample Patients
Snoring
Hab. snoring Apnea
%
%
%
A&T hypertrophy %
1
18
0
0
0
0
2
43
4.7
0
0
5
3
45
24.4
6.7
8 .0
22.7
4
52
32.7
5.8
8.7
30.6
5
38
52.6
7.9
5.9
48.6
6
36
47.2
11.1
15.8
45.5
7
30
50.0
13.3
11.1
41.4
8
17
47. 1
0
12.5
40.0
9
17
41.2
0
11.1
35.3
10
11
36.4
0
0
36.4
infectious symptoms of the upper airways referred for A&T surgery evaluation. On the basis of our usual clinical approach, derived from Pittsburgh criteria [5], 16 cases were indicated to surgical intervention (12 A&T, 1 T, 3 A), whilst the remaining 20 cases were not; the latter were considered as a 'control group'. The 'Event Index' (EI) was considered as the oximetric index. It was defined by the average number of 'respiratory events' per hour of sleep. In other words, EI was the number of times in which O2 tissular saturation drops below 4 %, that is to basal values. The average EI in the operated group (presurgical values) was 27.7 (SD 28.8) against 11.9 (SD 12.7) of the control group; this difference was statistically significative (t = -2.21, p = 0.03). A second recording carried out after an average of 18 days after surgical intervention (range 1-85) showed an average EI of 9.8 (SD 8.5). This data was statistically different from the presurgical values (EI 27.7) and similar to that of the control group (EI 11.9). Considering a normality criterion of 15 events per hour of sleep, 15 children out of 36 (41.6%) had oximetric data suggestive of OSAS: lOin the surgically treated group (10/16 = 62.5%) and 5 in the non operated group (5/20 = 25%). Out of the 10 surgically treated children with a presurgical EI > 15,8 had a normal index when recorded after the operation; the 2 remaining cases approached the extreme value of normality (EI 16.2, 18).
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
Age
274
De Benedetto/CudaiLeante
Table 2. A&T operations performed at ENT Department, Galatina Year
A,%
1986 1987 1988 1989 1990
86 76 55 37 32
A&T,%
11 31 52 59
T,%
Age
13
6.1
13 14 11
5.8 5.3 5.4 5.3
9
These data indicate a high prevalence of OSAS (probability diagnoses) in subjects with A&T diseases, estimated at about 40%. By referring to the usual ENT clinical indications for A&T surgery, the prevalence seems to be higher than 60% (sensitivity 60%) for surgically treated children and only 25 % for non surgically treated children (specificity 75 %). Moreover, it is quite likely that sensitivity data are underestimated since they also include cases that are prevailingly infectious within the group in question. Low specificity rate indicates that the current clinical approach must be revised in order to include cases of possible mild OSAS in treated group. A larger clinical criteria and/or a simple test such as oximetry need to be further evaluated in this respect.
During the 5 years from 1986 to 1990, 834 A&T surgical interventions were carried out at our Department. The percentages of the single operations per year as well as the average age of the patients with regards to the 1- to 10-year age group are shown in table 2. Operations of tonsillectomy alone are quite constant though there is a slight decrease in the last 2 years, whilst adenoidectomies have constantly decreased in favor of a growing number of A&T operations. The average age of intervention has decreased gradually to a steady age of about 5.3 years. This trend reveals an increasing number of surgical indications for obstructive problems with suspect OSAS; in fact, A&T operation represents at our Department the choice treatment for obstructive cases in this age group. A similar trend is referred to by Rosenfeld and Green [16].
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
Surgical Trends
Obstructive Sleep Apnea Syndrome and A&T Surgery
275
References
2 3 4 5 6 7 8 9 10 11 12 13 14
15 16
Bradley TD, Brown IG, Grossman RF: Pharyngeal size in snorers, nonsnorers and patients with obstructive sleep apnea. N Eng! J Med 1986;315: 1327-1331. Brouillette RT, Fernbach SK, Hunt CE: Obstructive sleep apnea in infant and children. J Pediatr 1982;100:31-40. Guilleminault C, Korobkin R, Winkle R: A review of 50 children with obstructive sleep apnea syndrome. Lung 1981;159:275-287. Eliasker I, Lovie P, Halperin E, Gordon C, Alroy G: Sleep apnea episodes as indications for adenotonsillectomy. Arch Otolaryngol 1980; 106:492-496. Paradise JL: Tonsillectomy and adenoidectomy; in Bluestone CD, Stool SE, Arjona SK (eds): Pediatric Otolaryngology. Philadelphia, Saunders, 1983, pp 992-1006. Potsic WP, Pasquariello PS, Baranak CC: Relief of upper airway obstruction by adenotonsillectomy. Otolaryngol Head Neck Surg 1986;4:476-480. Grundfast KM, Wittich DJ: Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope 1982;92:650-656. Mauer KW, Staats BA, Olsen KD: Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clin Proc 1983;58:349-353. Sidman JD, Fry TL: Exacerbation of sickle cell disease by obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1988; 114:916-917. Levy AM, Tabakin BS, Harrison JS: Hypertrophied adenoids causing pulmonary hypertension and severe congestive failure. N Eng! J Med 1967;277:506-511. Menashe VD, Fearron C, Miller M: Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 1965;67: 198-203. Noonan JA: Reversible cor pulmonale due to hypertrophied tonsil and adenoids. Circulation 1965;32(suppl 2): 164. Talbot AR, Robertson LW: Cardiac failure with tonsil and adenoid hypertrophy. Arch Otolaryngol 1973;98:272-281. Cuda D, Graziuso M, Leante M, Mauro N, Vitale S: Utilita della Sa02 nella diagnostica dell' apnea ostruttiva nel sonno in eta pediatrica. Atti III Incontro Interdisciplinare su: Le infezioni delle vie respiratorie - I disturbi respiratori nel sonno, Lecce 1990, pp 291-298. Corbo G, Fuciarelli F, Foresi A, De Benedetto F: Snoring in children: association with respiratory symptoms and passive smoking. Br Med J 1990;299: 1491-1494. Rosenfeld RM, Green RP: Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99:187-191.
Dr. Michele De Benedetto, Via Pascoli, 19,1-73013 Galatina, Lecce (Italy)
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
2
Obstructive Sleep Apnea Syndrome and A&T Surgery M . De Benedetto, D. Cuda, M. Leante ORL Department, S. Caterina Novella Hospital, Gaiatina, Leece, Italy
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
Obstructive sleep apnea syndrome (OSAS) can occur frequently in children with adenoid and tonsillar hypertrophy (A TH) [1-3]. It is well known that A&T surgery is a very effective treatment when obstructive symptoms are unequivocally attributable to ATH, affording complete relief [4-6]. For these reasons, OSAS represents a definite indication for A&T operation [4, 5]. OSAS is a disease potentially severe in children and it is characterized by a wide range of symptoms: sleep disturbances, diurnal manifestations (behavioral disturbance, excessive daytime somnolence) and in some cases severe cardiopulmonary sequelae [7-13]. It appears likely that OSAS may be more common than it is generally appreciated. The identification of children affected by OSAS is a difficult task because of poor knowledge of epidemiology and the difficulties in the diagnosis of disease. We consider three different levels of diagnostic definition of OSAS: 'suspect', 'likely' and 'definite'. 'Definite OSAS' is a diagnosis based on polysomnographic recordings. However, the poor availability of sleep laboratories, the costs and the possible nonacceptance preclude a large use of polysomnography in the pediatric population. 'Likely OSAS' is based on a simplified test that monitors tissular O 2 saturation during sleep. The evidence of several phasic drops in 02 saturation is strongly suggestive of OSAS in children with ATH [14]. Several clinical oximeters are now available and regular usage is also possible at the child's home. 'Suspect OSAS' is based on clinical data such as habitual snoring and/or direct parental observation of apneas during sleep in a child with significant ATH.
De Benedetto/CudalLeante
272
In order to quantify the problem of OS AS in relation to A&T surgery, in this paper we refer epidemiological data of 'suspect OSAS' and 'likely OSAS' in some clinical pediatric populations. We refer also about current A&T surgical trends at our Department.
'Suspect' OSAS A questionnaire concerning sleep disturbances and related problems was submitted to parents of 307 children aged 0-10 years (mean 4.7, SD 2.4) referred consecutively to their pediatrician for various clinical problems. 141 were girls and 166 were boys. In 101 cases (32.9%) snoring was referred to as occasional ('sometimes' or 'often') or habitual ('always'). Habitual snoring was described in only 17 cases (5.5%). Sleep apnea was referred to in 6.9% of cases. It is important to remember, however, that an answer to this question was difficult to obtain in 17.3% of cases due to the parents' lack of awareness about this sleep disorder. Significant ATH was mentioned by pediatricians in 30.2 % of the cases in question. Percentage data concerning the total prevalence of snoring and prevalence of habitual snoring alone, of apnea and of ATH per age groups, are shown in table 1; the close link between ATH and snoring is also emphasized. They present an overlapping age trend and similar prevalence. Prevalence reaches its peak between 5 and 7 years of age. Despite a few discrepancies in the upper age groups probably due to the low number of patients, habitual snoring and apnea also show a similar trend. In summary, from the gathered data we can conclude that about 30% of the children of the general pediatric practice have ATH strictly correlated to some sort of snoring. Cases with major obstruction (habitual snoring and apnea) were pinpointed in 5-7 % with a maximum peak at the age of 5-7 years. These data are in accord with Corbo et al. [15], who report a mean prevalence of habitual snorers of 7.3% in a large sample of children aged 6-13 years.
As an indicator of the likely presence of OSAS in children, we recorded O 2 tissular saturation during sleep with a transcutaneous electrode in 36 children (average age 4.6, SD 2.6) with obstructive and/or
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
'Likely' OSAS
273
Obstructive Sleep Apnea Syndrome and A&T Surgery
Table 1. Prevalence of snoring, apnea and A&T hypertrophy in a pediatric sample Patients
Snoring
Hab. snoring Apnea
%
%
%
A&T hypertrophy %
1
18
0
0
0
0
2
43
4.7
0
0
5
3
45
24.4
6.7
8 .0
22.7
4
52
32.7
5.8
8.7
30.6
5
38
52.6
7.9
5.9
48.6
6
36
47.2
11.1
15.8
45.5
7
30
50.0
13.3
11.1
41.4
8
17
47. 1
0
12.5
40.0
9
17
41.2
0
11.1
35.3
10
11
36.4
0
0
36.4
infectious symptoms of the upper airways referred for A&T surgery evaluation. On the basis of our usual clinical approach, derived from Pittsburgh criteria [5], 16 cases were indicated to surgical intervention (12 A&T, 1 T, 3 A), whilst the remaining 20 cases were not; the latter were considered as a 'control group'. The 'Event Index' (EI) was considered as the oximetric index. It was defined by the average number of 'respiratory events' per hour of sleep. In other words, EI was the number of times in which O2 tissular saturation drops below 4 %, that is to basal values. The average EI in the operated group (presurgical values) was 27.7 (SD 28.8) against 11.9 (SD 12.7) of the control group; this difference was statistically significative (t = -2.21, p = 0.03). A second recording carried out after an average of 18 days after surgical intervention (range 1-85) showed an average EI of 9.8 (SD 8.5). This data was statistically different from the presurgical values (EI 27.7) and similar to that of the control group (EI 11.9). Considering a normality criterion of 15 events per hour of sleep, 15 children out of 36 (41.6%) had oximetric data suggestive of OSAS: lOin the surgically treated group (10/16 = 62.5%) and 5 in the non operated group (5/20 = 25%). Out of the 10 surgically treated children with a presurgical EI > 15,8 had a normal index when recorded after the operation; the 2 remaining cases approached the extreme value of normality (EI 16.2, 18).
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
Age
274
De Benedetto/CudaiLeante
Table 2. A&T operations performed at ENT Department, Galatina Year
A,%
1986 1987 1988 1989 1990
86 76 55 37 32
A&T,%
11 31 52 59
T,%
Age
13
6.1
13 14 11
5.8 5.3 5.4 5.3
9
These data indicate a high prevalence of OSAS (probability diagnoses) in subjects with A&T diseases, estimated at about 40%. By referring to the usual ENT clinical indications for A&T surgery, the prevalence seems to be higher than 60% (sensitivity 60%) for surgically treated children and only 25 % for non surgically treated children (specificity 75 %). Moreover, it is quite likely that sensitivity data are underestimated since they also include cases that are prevailingly infectious within the group in question. Low specificity rate indicates that the current clinical approach must be revised in order to include cases of possible mild OSAS in treated group. A larger clinical criteria and/or a simple test such as oximetry need to be further evaluated in this respect.
During the 5 years from 1986 to 1990, 834 A&T surgical interventions were carried out at our Department. The percentages of the single operations per year as well as the average age of the patients with regards to the 1- to 10-year age group are shown in table 2. Operations of tonsillectomy alone are quite constant though there is a slight decrease in the last 2 years, whilst adenoidectomies have constantly decreased in favor of a growing number of A&T operations. The average age of intervention has decreased gradually to a steady age of about 5.3 years. This trend reveals an increasing number of surgical indications for obstructive problems with suspect OSAS; in fact, A&T operation represents at our Department the choice treatment for obstructive cases in this age group. A similar trend is referred to by Rosenfeld and Green [16].
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
Surgical Trends
Obstructive Sleep Apnea Syndrome and A&T Surgery
275
References
2 3 4 5 6 7 8 9 10 11 12 13 14
15 16
Bradley TD, Brown IG, Grossman RF: Pharyngeal size in snorers, nonsnorers and patients with obstructive sleep apnea. N Eng! J Med 1986;315: 1327-1331. Brouillette RT, Fernbach SK, Hunt CE: Obstructive sleep apnea in infant and children. J Pediatr 1982;100:31-40. Guilleminault C, Korobkin R, Winkle R: A review of 50 children with obstructive sleep apnea syndrome. Lung 1981;159:275-287. Eliasker I, Lovie P, Halperin E, Gordon C, Alroy G: Sleep apnea episodes as indications for adenotonsillectomy. Arch Otolaryngol 1980; 106:492-496. Paradise JL: Tonsillectomy and adenoidectomy; in Bluestone CD, Stool SE, Arjona SK (eds): Pediatric Otolaryngology. Philadelphia, Saunders, 1983, pp 992-1006. Potsic WP, Pasquariello PS, Baranak CC: Relief of upper airway obstruction by adenotonsillectomy. Otolaryngol Head Neck Surg 1986;4:476-480. Grundfast KM, Wittich DJ: Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope 1982;92:650-656. Mauer KW, Staats BA, Olsen KD: Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clin Proc 1983;58:349-353. Sidman JD, Fry TL: Exacerbation of sickle cell disease by obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1988; 114:916-917. Levy AM, Tabakin BS, Harrison JS: Hypertrophied adenoids causing pulmonary hypertension and severe congestive failure. N Eng! J Med 1967;277:506-511. Menashe VD, Fearron C, Miller M: Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 1965;67: 198-203. Noonan JA: Reversible cor pulmonale due to hypertrophied tonsil and adenoids. Circulation 1965;32(suppl 2): 164. Talbot AR, Robertson LW: Cardiac failure with tonsil and adenoid hypertrophy. Arch Otolaryngol 1973;98:272-281. Cuda D, Graziuso M, Leante M, Mauro N, Vitale S: Utilita della Sa02 nella diagnostica dell' apnea ostruttiva nel sonno in eta pediatrica. Atti III Incontro Interdisciplinare su: Le infezioni delle vie respiratorie - I disturbi respiratori nel sonno, Lecce 1990, pp 291-298. Corbo G, Fuciarelli F, Foresi A, De Benedetto F: Snoring in children: association with respiratory symptoms and passive smoking. Br Med J 1990;299: 1491-1494. Rosenfeld RM, Green RP: Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99:187-191.
Dr. Michele De Benedetto, Via Pascoli, 19,1-73013 Galatina, Lecce (Italy)
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 11:45:28 PM
2
