New Data on Tonsillectomy: Behavior Advantages and Best Technique

“The strength of the study is all the children had polysomnography, so there was an objective measurement of OSA or mild SDB, and all the children underwent a comprehensive behavioral assessment using a validated and well-used instrument,” Dr. Mitchell said. “Our results suggest that SDB is associated with a significant amount of behavioral morbidity regardless of severity, which is perhaps surprising, but these behavioral problems improve after adenotonsillectomy and that appears to be regardless of whether the children have mild SDB or OSA.”

More Behavior Improvements after Adenotonsillectomy

It has been well established that SDB has a negative impact on overall childhood development and, although polysomnography has always been considered the gold standard for the diagnosis and evaluation of OSA, children who are clinically diagnosed with SDB may not always meet polysomnography-defined criteria.

Although, the American Academy of Pediatrics recommends objective testing, including polysomnography, prior to surgery, a previously published survey of otolaryngology practice patterns found that less than 5% of school-age children receive preoperative polysomnography.

Although polysomnography has always been considered the gold standard for the diagnosis and evaluation of obstructive sleep apnea, children who are clinically diagnosed with SDB may not always meet polysomnography-defined criteria.

“Several studies have used quality-of-life instruments, either as an alternative or along with polysomnography, to assess the improvement in sleep and behavior after tonsillectomy and adenoidectomy,” said Julie L. Wei, MD, Assistant Professor of Otolaryngology and Pediatric Otolaryngology at the University of Kansas School of Medicine in Kansas City. “These studies have consistently found significant quality of life improvement after surgery.”

Two Measurement Scales

For their study, Dr. Wei and her colleagues chose two instruments to measure change in sleep and behavior after tonsillectomy and adenoidectomy—the Pediatric Sleep Questionnaire (PSQ) and the Connor’s Parent Rating Scale-Revised Short form (CPRS-RS) for assessing behavior.

The PSQ is a validated 74-item list of questions that ask about children’s sleep habits and behavior, but within it is a sleep-related breathing disorder subscale which has been shown to predict poly-confirmed SDB with good reliability and validity, Dr. Wei noted.

The CPRS-RS is an instrument that is widely used, especially in treatment studies by pediatric behavioral specialists, mainly to measure change in symptoms. It has within it four behavioral subscales: oppositional behavior, cognitive problem or inattention, hyperactivity, and an attention deficit–hyperactivity disorder index.

This was a prospective observational study in which 117 children age 3–17, who were undergoing adenotonsillectomy to treat SDB were invited to participate. The parents and caregivers completed the PSQ and the CPRS-RS the day of surgery and once again six months after surgery.

Correlations Found

“Linear correlations were found between sleep and behavior and were found to be statistically significant before surgery for three out the four Connor’s subscales,” Dr. Wei said. “We found them statistically significant for everything except hyperactivity. And they were found to be statistically significant postoperatively for cognitive problems and oppositional behavior.”