Chicago—Sleep disordered breathing (SDB) encompasses a spectrum of problems that range from primary snoring to obstructive sleep apnea. Numerous studies have established an association between SDB and behavioral problems in children. For children diagnosed with adenotonsillar hypertrophy, the primary treatment is adenotonsillectomy, which has been shown to improve both respiratory parameters and behavior.
Explore This IssueJuly 2006
But do children’s mild or severe behavioral problems necessarily correlate with the result of polysomnography, and to what degree are sleep and behavior improved? And, when surgery is indicated, what is the preferable adenotonsillectomy technique?
The results of three separate studies looking at those questions were presented here during the American Society of Pediatric Otolaryngology program at the 2006 Combined Otolaryngology Spring Meeting (COSM).
Behavior Changes after Adenotonsillectomy
The objectives of the first study were to compare children with mild SDB to children with obstructive sleep apnea, as far as their behavioral problems were concerned, and to determine whether adenotonsillectomy improved these children’s conditions to a lesser or greater degree. The study population included 40 children between the ages of 3 and 18; 23 diagnosed with obstructive sleep apnea (OSA) and 17 with mild SDB.
“Following polysomnography, the children’s caregivers completed a behavioral scale using the BASC system, which is a behavioral assessment system for children,” said Ron B. Mitchell, MD, Associate Professor and Director of Pediatric Otolaryngology–Head and Neck Surgery at the Virginia Commonwealth University Medical Center in Richmond. “BASC is a multidimensional instrument which consists of about a hundred questions.”
Preoperative measurements based on the BASC were compared, as well as the results of BASC after surgery. The mean apnea-hypopnea index (AHI) for the OSA group was 25.3 and the equivalent number for the mild SDB group was 3.1, Dr. Mitchell reported. The follow-up period was approximately three months in both groups and the demographics were similar.
“Looking at the measurements before surgery, the behavior symptom index (BSI) and the clinical parameters were very similar between the two groups, slightly higher in the OSA group, but the differences were not significant,” Dr. Mitchell said. “The differences before and after surgery, however, were highly significant.”
“If one could design the ideal [tonsillectomy] surgery, it would be painless with no risk of bleeding and would lead to the immediate resumption of a normal diet and activity.” – —Richard Schmidt, MD
The BSI, which is a global measure of behavior, showed significant improvement after surgery for both groups of children. The children showed improvement after adenotonsillectomy in the BASC scales of atypicality, depression, hyperactivity, and somatization.
“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.
“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.”
She added, though, that the lack of agreement between polysomnography parameters and clinical diagnosis makes diagnosing all children with SDB a continual challenge
“Quality of life instruments are very different in nature compared with polysomnography, so they may in fact represent a different aspect of the SDB spectrum,” she said. “Our data demonstrates an association between adenotonsillectomy and improvement in sleep and behavior as measured by the PSQ and the Connor’s instrument. Treatment of children with clinically diagnosed SDB, even if not confirmed with polysomnography, can still result in improvement of behavior and sleep and the PSQ may be used as a screening tool and as an adjunct to clinical history and exam when determining candidacy for surgery, especially when polysomnography is not feasible.”
Tonsillectomy has been around for more than 2,000 years and has been performed countless times, yet it is not without certain morbidities, the most prevalent of which are postoperative pain or bleeding.
“If one could design the ideal surgery, it would be painless with no risk of bleeding and would lead to the immediate resumption of a normal diet and activity,” said Richard Schmidt, MD, a pediatric otolaryngologist at the A.I. DuPont Hospital for Children in Wilmington, Del. “Over the last couple of decades, new technologies have come to the forefront and have held promise, but with widespread use, have frequently not lived up to that promise.”
A previously published study of patients treated with intracapsular tonsillectomy, compared to a similarly sized group of patients treated with standard tonsillectomy, found that fewer patients in the intracapsular group experienced delayed bleeding or required re-admission for dehydration.
A previously published study of patients treated with intracapsular or standard tonsillectomy found that fewer patients in the intracapsular group experienced delayed bleeding or required re-admission for dehydration.
“It is believed that pain is lessened after this procedure because the capsule is left behind. We believe that inflammation of the pharyngeal constrictor muscles after tonsillectomy is the cause of most of the postoperative pain that patients experience and, by leaving the tonsillar capsule behind, the muscles are protected from inflammation and they act like sort of a biological dressing.”
Likewise, bleeding may be lessened after the procedure because the larger primary tonsillar vessels are not exposed due to the small amount of tonsillar tissue and capsule left behind, he added.
“Our hypothesis was that children undergoing intracapsular tonsillectomy (IT) have less pain and lower incidence of secondary hemorrhage than those receiving traditional tonsillectomy (TT),” he said. “We did a retrospective chart review; we looked at the technique used, the indications for surgery, patient age, gender and length of follow-up.”
Outcome measures were secondary hemorrhages and the need for the patient to be seen in the emergency department or re-admitted for pain, or dehydration attributed to pain, and the need for additional surgery related to adenotonsillar disease.
The study group included 1,731 patients in the IT group and 1,213 in the TT group.
“In general, it was the bleeds that required return visits to the OR that were most concerning,” he said. “One concern about partial tonsillectomy is the potential need for additional surgery or revision surgery. Fortunately, this was not common in our patients; out of 1,731, only 11 required revision tonsillectomy. Overall, we found that IT seems to have a lower risk of secondary hemorrhage and less pain requiring hospital-based management. These findings seem to be consistent with the changing trends for [tonsillectomy and adenoidectomy] surgery.”
©2006 The Triological Society