Tonsillectomy and Adenoidectomy (T&A)
Sally R. Shott , MD
Upper Airway Center Cincinnati Children’s Hospital
First Line Surgical Treatment For Sleep Disordered Breathing And Obstructive Sleep Apnea Expectations And Outcomes
Two different scenarios are often seen: Scenario 1: Your child is snoring, moving all over the bed, working to breathe, waking up repeatedly throughout the night, and sometimes seems to stop breathing. He/she is just NOT getting a good night sleep. You bring up these concerns to your pediatrician and they refer you to an Ear, Nose, and Throat (ENT) doctor and removal of the tonsils and adenoids, commonly called a “T&A”, is recommended.
Or Scenario 2: Your child does NOT snore, is a bit restless, but overall sleeps well, waking up only occasionally and seems to be getting a good night sleep. However, your child has a sleep study done at around 4 years old, as recommended by your primary care doctor and the American Academy of Pediatrics guidelines for medical care for children with Down syndrome (DS). The sleep study shows obstructive sleep apnea (OSA). You are referred to an ENT doctor and a T&A is recommended.
Your question for the ENT doctor may be: What are the chances that the T&A will CURE my child’s sleep abnormalities and sleep apnea? Will further treatment be needed? Will more surgery be needed or are there medical treatments such as medications that could be helpful?
Removal of the tonsils and adenoids, or T&A, is the most common first line surgical treatment for upper airway obstruction and sleep disordered breathing in children. The term “sleep disordered breathing” is a continuum of airway obstruction, starting with symptoms of mild snoring, which can have minimal side effects, and progresses in severity to obstructive sleep
apnea with periods of partial or complete obstruction during sleep, frequently associated with drops in oxygen levels. Poor quality sleep and especially obstructive sleep apnea can affect overall quality of life, and result in abnormal daytime behavior, decreased school performance, memory impairment, and can affect brain development and neurocognitive function, including decreased IQ scores (1). Although most of the studies looking at the complications associated with untreated OSA and sleep disordered breathing have been done in children who do not have DS, more recent studies have specifically addressed these problems in children with DS and have similarly shown that poor sleep impacts executive function and behavior in school-age children with DS (2,3). In the long term, OSA can lead to systemic hypertension, pulmonary hypertension, heart failure and worse. Because 50% of children with DS have underlying cardiac abnormalities at birth, there is a concern that these more serious complications can occur more often in those with DS (4).
In children, because the tonsils and adenoids frequently take up a large proportion of the upper airway, T&A is suggested to enlarge the upper airway. In children with Down syndrome, the tonsils and adenoids are also one of the main contributors to upper airway obstruction – but it is also more complicated. In children with DS, the midface and mandible – the area of the mouth, nose, back of the throat and airway down to the level of the voice box – are frequently smaller compared to other children. In addition, there is relative enlargement of the tongue, low tone in body tissues so they collapse more easily and obesity is more common in DS. When asleep, the upper airway relaxes and collapses, just like the rest of the body relaxes with sleep. Because the upper airway is already smaller, obstruction during sleep is more common in children with DS. Whereas the prevalence of OSA is only 1-5% in the general pediatric population, studies have shown that by age 4, almost 60% of children with DS have sleep abnormalities and OSA and this increases to 90% by age 9 (5,6).
Studies have also shown that because children with DS do not always have the classic signs of obstruction with sleep, such as snoring, snorting and obvious pauses, parents are not always able to identify sleep problems (7-9). This is one of the main reasons the American Academy of Pediatrics recommends that all children with DS have a polysomnogram, commonly referred to as a sleep study, by age 4 years. The sleep study provides objective data regarding sleep behaviors. The sleep study provides a lot of information regarding sleep patterns and one of them is called the obstructive index’. This number represents the episodes per hour, of total or partial obstruction during sleep, with associated drops in oxygen levels. An obstructive index of less than 1 per hour is normal for children. An obstructive index of 1-5 per hour is consistent with mild obstructive sleep apnea. Moderate sleep apnea is present with an obstructive index of 5-10 and an obstructive index of over 10 would be consistent with severe sleep apnea.
It can be confusing to read papers on outcomes after T&A surgery because different definitions of ‘success’ are used. Many will refer to a ‘failed’ post-operative result only when the obstructive index is greater than 5 after the T&A. They might do this because in cases of mild residual OSA, where the obstructive index is between 1-5, medications can be used to treat this residual obstruction, along with continued monitoring. However, in this review, a “cure” is defined as an obstructive index after T&A of less than 1, where no further sleep study monitoring or medical or surgical treatment is needed.
Doctors used to believe that since the tonsils and adenoids take up such a proportionally large area of the upper airway, a T&A would cure all sleep obstruction, particularly in children with
no other significant medical problems. However, studies have shown that this is not true. A paper in 2009 reviewing the combined results of 9 studies showed a cure rate of 60-66% after T&A
10). In these 9 studies, children with craniofacial anomalies, including those with DS were excluded. In a 2010 multi-center study of almost 600 children, with no chromosomal abnormalities or systemic illnesses, only 27% had a full cure after T&A. About 50% of the children had persistent mild OSA after their T&A. Twenty-one percent continued to have moderate to severe sleep pnea after the T&A and required further medical and/or surgical treatment. Risk factors for residual obstruction were obesity, asthma, more severe obstruction pre-operatively, and age over 7 years (11).
Children with DS have an even higher chance of having residual OSA after their T&A. On review of studies done specifically analyzing results after T&A in children with DS, cure rates ranged between 11 and 52 % with an average of 17%. The highest success rates were found when the mean age of the children studied was the youngest. Mild residual OSA after T&A, where further treatment with only medications may be needed to treat the residual obstruction, occurred in approximately 39%. Moderate to severe OSA remained in 40-50%. (12-17)
Although outcomes after T&A are not as good in children with DS, all these studies showed a statistically significant improvement in the overall sleep apnea severity after T&A. One paper did a
quantitative analysis of the most complete studies available and found that in children with DS, a 51% reduction in the degree of OSA can be expected from T&A alone (14).
Because studies on children with DS undergoing T&A showed a higher incidence of post-operative respiratory complications that can require treatment with oxygen, as well as a longer duration for adequate fluid intake to occur, overnight observation in the hospital after T&A is recommended (18). In addition, because of the higher incidence of residual moderate to severe obstruction after T&A, it is important for children with DS to have a post-operative sleep study approximately 3 months after their T&A. Outcomes from the surgery can’t be accurately predicted by parents’ reports alone. Although further treatment may be needed to treat residual OSA, T&A is still felt to be the best first line of surgical treatment for OSA in children with DS. Studies have shown that the improved sleep after T&A in children with DS improves quality of life and improves both achievement testing and behavior in school (19).
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References
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