Tonsils at Telethon: developing a standardised collection of tonsil photographs for group A streptococcal (GAS) research

Introduction

Group A streptococcus (GAS) infections, such as pharyngitis and impetigo, can lead to rheumatic fever and rheumatic heart disease (RHD). Australian Aboriginal and Torres Strait Islander populations experience high rates of RHD and GAS skin infection, yet rates of GAS pharyngitis are unclear. Anecdotally, clinical presentations of pharyngitis, including tonsillar hypertrophy and sore throat, are uncommon. This study aimed to develop a standardised set of tonsil photographs and determine tonsil size distribution from an urban paediatric population.

Methods

A prospective cohort of children aged 3-15 years were recruited at the public events "Discover Day" and "Telethon Weekend" (October 2017) in Perth, Western Australia, Australia. Tonsil photographs, symptomatology, and GAS rapid antigen detection tests (RADT) were collected. Tonsil size was graded from the photographs using the Brodsky Grading Scale of tonsillar hypertrophy (Brodsky) by two independent clinicians, and inter-rater reliability calculated. Pharyngitis symptoms and GAS RADT were correlated, and immediate results provided.

Results

Four hundred and twenty-six healthy children participated in the study over three days. The median age was seven years [interquartile range (IQR) 5.9-9.7 years]. Tonsil photographs were collected for 92% of participants, of which 62% were rated as good-quality photographs and 79% were deemed of adequate quality for assessment by both clinicians. When scored by two independent clinicians, 57% received the same grade. Average Brodsky grades (between clinicians) were 11%, 35%, 28%, 22% and 5% of grades 0,1,2,3 and 4, respectively. There was moderate agreement in grading using photographs, and minimal to weak agreement for signs of infection. Of 394 participants, 8% reported a sore throat. Of 334 GAS RADT performed, <1% were positive.

Discussion

We report the first standardised use of paediatric tonsil photographs to assess tonsil size in urban-living Australian children. This provides a proof of concept from an urban-living cohort that could be compared with children in other settings with high risk of GAS pharyngitis or rheumatic fever such as remote-living Australian Indigenous populations.

The association of tonsillar microbiota with biochemical indices based on obesity and tonsillar hypertrophy in children

The correlation between tonsil microbiome and tonsillar hypertrophy has not been well established. Given that oral dysbiosis is related to several metabolic diseases and that tonsillar hypertrophy leads to disordered breathing during sleep and obesity in children, it is necessary to investigate the relationship between the oral microbiome and tonsillar hypertrophy. After 16S rRNA amplicon sequencing of tonsillectomy samples, we evaluated the correlation between the tonsil microbiome and biochemical blood indices in pediatric patients who underwent tonsillectomy. Groups are classified into two categories: based on BMI, and grades 2, 3, and 4 based on tonsil size. Children with obesity and tonsillar hypertrophy have similar microbiome compositions and induce comparable changes in microbiome abundance and composition, confirming the association from a metagenomic perspective. In addition, obesity and tonsillar hypertrophy demonstrated a strong correlation with the Proteobacteria to Firmicutes (P/F) ratio, and among various biochemical indicators, alanine aminotransferase (ALT) levels increase with obesity and tonsillar hypertrophy, indicating a possible association of tonsil microbiome and liver metabolism. These novel findings demonstrate the significance of the tonsil microbiome and suggest the need for tonsil regulation, particularly during childhood.

Role of the tonsil-oropharynx ratio on lateral cephalograms in assessing tonsillar hypertrophy in children seeking orthodontic treatment

OBJECTIVES

To analyze the diagnostic value of the tonsil-oropharynx (T/O) ratio on lateral cephalograms for evaluating tonsillar hypertrophy (TH).

METHODS

A cross-sectional study was performed on 185 consecutive children (101 males, 84 females; mean age 7.3 ± 1.4 years) seeking orthodontic treatment. The T/O ratios on lateral cephalograms were calculated following Baroni et al.'s method. Tonsil sizes were clinically determined according to the Brodsky grading scale. Spearman correlation coefficients between the T/O ratio and clinical tonsil size were calculated with the total sample and subgroups and then compared between subgroups. Diagnostic value was analyzed using the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive and negative predictive values, and accuracy.

RESULTS

There was a strong correlation between the T/O ratio and clinical tonsil size in children (ρ = 0.73; P < 0.001). A significantly higher correlation coefficient was found in the Class III children. The ROC curve revealed an area under the curve of 0.90 (95% CI, 0.86-0.94; P < 0.001). The optimal cutoff value of the T/O ratio for predicting TH was 0.58, with a sensitivity of 98.7% and specificity of 64.2%. Employing the cutoff value of 0.5, the sensitivity was 100% and the specificity was 45.9%.

CONCLUSIONS

Measurement of the T/O ratio on lateral cephalograms may be helpful to initial screening in children for TH. Practitioners may combine the clinical examination of tonsil size with the cephalometric findings for a more comprehensive evaluation.

Unilateral tonsil enlargement in children and adults: is routine histology tonsillectomy warranted? A multi-centre series of 323 patients

BACKGROUND

This study aimed to establish whether histology tonsillectomy is justified for unilateral tonsil enlargement.

METHODS

A retrospective review was conducted of histology tonsillectomies in three health organisations over five years, with strict exclusion criteria, focusing on benign-appearing unilateral tonsil enlargement.

RESULTS

Ninety paediatric and 233 adult cases were included. No paediatric cases and five adult cases of malignancy were detected. All malignant cases presented with other symptoms. Using binary logistic regression, a history of rapid unilateral tonsil enlargement was the only factor found to be significantly associated with malignant outcome. Thirty-three per cent of subjectively larger tonsils were smaller on post-operative histological measurement. Of the cases, 12.1 per cent re-presented with post-tonsillectomy bleeding.

CONCLUSION

The authors recommend avoiding histology tonsillectomy for unilateral tonsil enlargement unless 'red flag' signs of malignancy are present, with particular attention to rapid unilateral tonsil enlargement. This study demonstrated discrepancy between clinical examination findings and true tonsil asymmetry; there may be a role for cross-sectional imaging prior to histology tonsillectomy in high-risk patients.

Sleep Bruxism in Children—What Can Be Learned from Anamnestic Information

Sleep bruxism (SB) is a masticatory muscle activity during sleep, and its clinical manifestation in young children is still unclear. The aim of the present study was to evaluate the role of anamnestic information in predicting possible SB in children aged 4–12 years. In a cross-sectional retrospective exploratory study, the dental files of 521 children were examined with regard to the following anamnestic information: gender, age, medical conditions associated with ear, nose, and throat (ENT), respiratory disorders, use of methylphenidate (Ritalin), oral habits, and bruxing during sleep. A child was defined as presenting possible SB when a positive report was received from parents regarding such behavior (SB positive, No. = 84). There were no age- and/or gender-wise differences between SB-positive children and children whose parents did not report SB behavior (SB negative). SB-positive children suffered more from ENT and respiratory disorders than children without SB. Additionally, the use of pacifiers/finger sucking, as well as snoring, were more common among SB-positive children as compared to their SB-negative counterparts (Chi-square). The variables which were found to significantly increase the odds of possible SB in children were mouth breathing, ENT problems, and use of a pacifier or finger sucking (forward stepwise logistic regression). Clinicians should look for clinical signs of possible SB in children whose anamnesis reveals one or more of these anamnestic signals.

Machine Learning Identification of Obstructive Sleep Apnea Severity through the Patient Clinical Features: A Retrospective Study

OBJECTIVES

To evaluate the role of clinical scores assessing the risk of disease severity in patients with clinical suspicion of obstructive sleep apnea syndrome (OSA). The hypothesis was tested by applying artificial intelligence (AI) to demonstrate its effectiveness in distinguishing between mild-moderate OSA and severe OSA risk.

METHODS

A support vector machine model (SVM) was developed from the samples included in the analysis (N = 498), and they were split into 75% for training (N = 373) with the remaining for testing (N = 125). Two diagnostic thresholds were selected for OSA severity: mild to moderate (apnea-hypopnea index (AHI) ≥ 5 events/h and AHI < 30 events/h) and severe (AHI ≥ 30 events/h). The algorithms were trained and tested to predict OSA patient severity.

RESULTS

The sensitivity and specificity for the SVM model were 0.93 and 0.80 with an accuracy of 0.86; instead, the logistic regression full mode reported a value of 0.74 and 0.63, respectively, with an accuracy of 0.68. After backward stepwise elimination for features selection, the reduced logistic regression model demonstrated a sensitivity and specificity of 0.79 and 0.56, respectively, and an accuracy of 0.67.

CONCLUSION

Artificial intelligence could be applied to patients with symptoms related to OSA to identify individuals with a severe OSA risk with clinical-based algorithms in the OSA framework.

Investigating factors influencing post-operative growth in pre-pubertal children after adenotonsillectomy

PURPOSE

To check the change in growth-for-age after adenotonsillectomy in pre-pubertal children and investigate the affecting factors.

METHODS

Two hundred and six pediatric patients who underwent adenotonsillectomy by a single surgeon between January 2011 and December 2014 were included for the retrospective cohort study. The z-scores of height-, weight-, and body mass index (BMI)-for-age were measured before adenotonsillectomy and 1 year after the operation. The Korean version of the obstructive sleep apnea-18 questionnaire (OSA-18), symptom questionnaire, physical examinations, demographic data, and pre-operative z-scores were used to analyze the factors affecting z-score change.

RESULTS

Among 206 pediatric patients, 167 patients were normal growth; 19 were undergrowth; and 20 were obese. After the operation, height, weight, and BMI z-scores all increased both in 167 normal-growth patients and 19 undergrowth patients (p value < 0.05). However, in 20 obese patients, only height z-score significantly increased (p value = 0.028). The multiple regression test showed that the sleep disturbance domain of OSA-18 was positively correlated with height z-score change (p value = 0.041), and age was negatively correlated with weight z-score change (p value = 0.016). Pre-operative BMI z-score was negatively correlated (p value = 0.019) and adenoid grade was positively correlated (p value = 0.023) with BMI z-score change.

CONCLUSIONS

These findings suggest that adenotonsillectomy may positively affect growth in pre-pubertal children, without undesirable weight gain. Additionally, the sleep disturbance domain of OSA-18 may play a role in predicting post-operative height increase in pre-pubertal children.

The effect of adenotonsillectomy on pulmonary hypertension in pediatric obstructive sleep apnea

Background

In a majority of OSA children with adenotonsillar hypertrophy, very mild symptoms or no symptoms at all are related to the cardiopulmonary system, but symptomless chronic changes may slowly occur in these children. Therefore, it is wise to monitor these patients by an easy, noninvasive cost-effective method; this can easily be done by monitoring mean pulmonary artery pressure (mPAP) of these children with Doppler echocardiography. Doppler echocardiography has been demonstrated to have a perfect correlation with cardiac catheterization. This study aims to determine the pulmonary arterial systolic pressure (PASP) in OSA children with hypertrophied tonsils and adenoid and to clarify whether adenotonsillectomy has any effect on pulmonary arterial pressure of these children.

Methods

Study was conducted on 50 children of both sexes aged from 4 to 15 years. Children complain of loud snoring and obstructive sleep apnea due to hypertrophied tonsils and adenoids. Children fit for general anesthesia and adenotonsillectomy. In all subjects, Doppler echocardiography was done before and after adenotonsillectomy.

Results

Comparison between preoperative PASP and after 2 months showed that normal PASP were found in 25 (50.0%) and 50 (100.0%) for preoperative and after 2 months respectively. There was statistically significant difference between preoperative PASP and after 2 months. However, there was no correlation between preoperative PASP and age, sex, or duration of symptoms.

Conclusion

From this study, we conclude that adenotonsillar hypertrophy causes higher PASP in OSA children, PASP is worse in neglected OSA cases with long duration of symptoms, and adenotonsillectomy is an effective therapeutic measure in such patients.

Risk factors and antibiotic sensitivity of aerobic bacteria in Chinese children with adenoid hypertrophy

BACKGROUND

Bacterial infection of adenoid is currently considered to be an important cause of adenoid hypertrophy (AH) in children. Although several bacteriology studies on adenoid diseases have been reported, the aerobic bacterial study regarding risk factors and antibiotic sensitivity of AH in Chinese children is lacking. This study aims to investigate the risk factors for aerobic bacterial colonization of AH in Chinese children and to elucidate aerobic bacterial profiles and antibiotic sensitivity.

METHODS

Samples were collected from the adenoid core and surface tissue of 466 children undergoing adenoidectomy. Aerobic cultures and antibiotic sensitivity were observed. The risk factors for bacterial colonization of adenoid were analyzed statistically.

RESULTS

A total of 143 children could be detected opportunistic pathogens in adenoid surface and/or core tissue, with a carriage rate of 30.7%. The presence of chronic rhinosinusitis, tonsillar hypertrophy and adenoidal size were the risk factors for aerobic bacterial colonization of adenoid in univariate analysis. Multivariate analysis showed that chronic rhinosinusitis and tonsil hypertrophy were significant variables associated with the aerobic bacterial colonization. The most frequently isolated aerobic bacteria were Haemophilus influenzae, followed by Staphylococcus aureus and Streptococcus pneumoniae. There was no statistically significant difference in bacterial species between the adenoid surface and core. The above common bacteria were more sensitive to cephalosporins and quinolones antibiotics, and significantly resistant to penicillin antibiotics and non-β-lactamase inhibitors.

CONCLUSION

Our results provide recent aerobic bacterial profiles for AH among Chinese children and confirm the risk factors and antibiotic sensitivity. This study contributes to understanding the role of different risk factors in the development of AH and will be helpful to the treatment of AH among Chinese children.

Intrapatient Comparison of Coblation versus Electrocautery Tonsillectomy in Children: A Randomized, Controlled Trial

Many surgical instruments have been introduced and compared for safety and surgical efficiency in tonsillectomy. This study aimed to compare postoperative pain between coblation and conventional monopolar electrocautery tonsillectomy by intrapatient comparison in children. Thirty pediatric patients over six years of age undergoing tonsillectomies were enrolled. Coblation and electrocautery were used to remove both tonsils in one patient; one was removed by coblation and the other by electrocautery. The coblation side was randomly selected, and it was blinded to the patients. Each side’s daily pain scores were collected on the visual analogue scale (VAS) during ten postoperative days. On the day of surgery, 22 (73%) patients identified less pain on the coblation side, while others felt similar pain. The mean pain scores were significantly lower on the coblation side during the postoperative ten days (except for the 6th and 8th) than on the electrocautery side. The duration of severe pain (VAS > 5) was significantly shorter on the coblation side than on the electrocautery side (2.0 versus 3.7 days, respectively; p = 0.042). Coblation tonsillectomy induced less pain than electrocautery in pediatric patients; therefore, surgeons could choose the coblator as a surgical instrument for tonsillectomy to improve the pediatric postoperative quality of life.

The impact of the Adenotonsillectomy on cardiac functions and oxidative stress

OBJECTIVE

Obstructive sleep apnea syndrome (OSAS) causes cardiovascular comorbidities and increased oxidative stress. Adenotonsillectomy is the first treatment option for OSAS secondary to adenotonsillar hypertrophy (ATH). This study evaluated the presence of cardiovascular changes, hypertension and oxidative stress before and after adenotonsillectomy in patients with OSAS secondary to ATH.

METHODS

Patients with ATH diagnosed with OSAS by polysomnography (PSG) were included. All participants received an Echocardiography (ECHO) and 24-h ambulatory blood pressure measurement (ABPM). Serum malonyldialdehyde (MDA) and total oxidant activity (TOS) levels of oxidant parameters; total antioxidant activity (TAS), catalase (CAT), superoxide dismutase (SOD) and glutathione (GSH) levels of antioxidant parameters were measured. All patients received an adenotonsillectomy. Postoperative evaluation was performed at the 6th month. In the postoperative period, PSG, ECHO, ABPM and the oxidant-antioxidant parameter levels in the serum was repeated.

RESULTS

Twenty-eight patients (13 males, 15 females; mean age 8.2 ± 2.06 years) were included in the study. In the preoperative period, concentric remodeling was observed in 14,8% of the patients, although they had no cardiovascular system complaints. The apnea-hypopnea index (AHI) scores were classified as mild in 39.3% (n = 11), moderate in 21.4% (n = 6) and severe in 39.3% (n = 11) preoperatively. In the postoperative period, 22 patients were evaluated. It was observed that the severity of OSAS decreased, ventricular functions improved, oxidant parameters decreased and antioxidant parameters increased postoperatively.

CONCLUSION

Adenotonsillectomy provides a positive change in cardiovascular system parameters and an antioxidant change in the oxidative balance in patients with OSAS.

Versatility and Benefits of 4.0mm Flexible Nasal Endoscopy in 118 Children up to 10 Years of Age

Purpose

This retrospective study looked at the feasibility of using adult 4.0 mm flexible nasendoscopes (FNE) examination under local anesthetic (LA) in children three to 10 years old to diagnose adenoid hypertrophy (AH) and other conditions. We also looked for a correlation between the adenoid size on FNE and a) tonsil size, b) the typical symptoms of snoring, mouth breathing, impaired hearing, and apnoeic episodes c) the management options of otitis media with effusion (OME) and d) the adenoid size intraoperatively.

Methods

A retrospective, observational study of 118 children in an NHS pediatric otolaryngology clinic led by a single consultant. One hundred ten consecutive patients with suspected AH were divided into two groups of three to five years and six to 10 years. We compared the acceptance rate to FNE in two subgroups (three to five years and six to 10 years old) and examined the correlation between various parameters as outlined above, using the Chi-square test. Eight children underwent FNE for other reasons of change of voice and epistaxis.

Results

FNE was successfully performed in 86% of the patients without restraint. Thirty-three percent of patients had non-obstructive adenoids (OA) and did not require surgical intervention. The intraoperative adenoid size, symptoms of snoring, mouth-breathing, and apnoeic episodes positively correlated with OA; however, no correlation was seen with the tonsil size (p=0.1143). All patients with OA and type B tympanogram needed adenoidectomy and grommet insertion (p=0.0119), and those with type C curves recovered with adenoidectomy alone.

Conclusions

4.0 mm adult scope helped reach a definitive diagnosis for AH in most children above three years of age, thus proving cost-effective. The symptoms of snoring, mouth-breathing, and apnoeic episodes had a positive correlation to the presence of OA; however, the tonsil size was seen to be independent of adenoid size.

Primary surgical management can be considered the treatment of choice for all patients with OA and type B tympanogram without a trial of conservative therapy.

Sleep-disordered breathing in children and adolescents seeking paediatric dental care in Dubai, UAE

PURPOSE

This study aimed to evaluate the severity of high-risk SDB in children and adolescents seeking paediatric dental care. Sleep-disordered breathing (SDB) has many untoward consequences that may interfere with children's health and is associated with several risk factors.

METHODS

In this cross-sectional study, the convenience sample included 65 healthy children and adolescents aged 7-16. High-risk SDB breathing was assessed using the Paediatric-Sleep-Questionnaire consisting of 22 questions. High-risk was defined as a positive response to 33% or more of the questions. The clinical examination included: tonsils' size, Body-Mass Index, orthodontic examination, and enamel defects.

RESULTS

In this sample of 65 children with a mean age of 9.75 (± 2.60) years; 36 (55.4%) were boys, and 29 (44.6%) were girls. Overall, 12.3% of children in the sample were at high-risk of SDB, and this was significantly associated with tonsils' size (P = 0.001), Body-Mass Index (P = 0.03), Class-II molar relationship (P = 0.03), and posterior crossbite/s (P = 0.02).

CONCLUSIONS

This study suggested that approximately 12% of the sample studied were potentially at risk of SDB. Tonsils' size, Body-Mass Index, Class-II molar relationship, and posterior crossbite/s were positively associated with the risk of SDB. Therefore, the importance of investigating the risk for sleep-disordered breathing should not be disregarded.

Screening Severe Obstructive Sleep Apnea in Children with Snoring

Efficient screening for severe obstructive sleep apnea (OSA) is important for children with snoring before time-consuming standard polysomnography. This retrospective cross-sectional study aimed to compare clinical variables, home snoring sound analysis, and home sleep pulse oximetry on their predictive performance in screening severe OSA among children who habitually snored. Study 1 included 9 (23%) girls and 30 (77%) boys (median age of 9 years). Using univariate logistic regression models, 3% oxygen desaturation index (ODI3) ≥ 6.0 events/h, adenoidal-nasopharyngeal ratio (ANR) ≥ 0.78, tonsil size = 4, and snoring sound energy of 801–1000 Hz ≥ 22.0 dB significantly predicted severe OSA in descending order of odds ratio. Multivariate analysis showed that ODI3 ≥ 6.0 events/h independently predicted severe pediatric OSA. Among several predictive models, the combination of ODI3, tonsil size, and ANR more optimally screened for severe OSA with a sensitivity of 91% and a specificity of 94%. In Study 2 (27 (27%) girls and 73 (73%) boys; median age, 7 years), this model was externally validated to predict severe OSA with an accuracy of 76%. Our results suggested that home sleep pulse oximetry, combined with ANR, can screen for severe OSA more optimally than ANR and tonsil size among children with snoring.

Intratonsillar detection of 27 distinct viruses: A cross-sectional study

Palatine tonsils have been observed to harbor several distinct respiratory and herpesviruses in separate studies. In this study, the presence of these viruses in palatine tonsils was comprehensively studied in both children and adults. A cross-sectional analysis of 181 patients (median age 22 years; range, 2.6-66) operated for a benign tonsillar disease was conducted. Real-time polymerase chain reaction was performed to detect 27 distinct viruses in all: eight human herpesviruses, 16 respiratory viruses, parvo B19, and polyoma BK/JC viruses. Clinical characteristics of the patients and underlying conditions were evaluated. In total, 92% of patients had virus detected in tonsils (Epstein-Barr virus 72%, human herpesvirus 7, and 6B 54% and 16%, respectively, enterovirus 18%, parvovirus B19 7% and the rest <4%). No herpes simplex virus 2, varicella zoster virus, polyoma JC virus, parainfluenza-, metapneumo-, or coronaviruses were found. Enterovirus was more common in children and was frequently observed in the presence of HHV6B. None of the viruses showed a positive association to the tonsillar disease. Respiratory symptoms were not associated with the prevalence of viruses. This study comprehensively reports a cross-sectional view of intratonsillar virus infections in elective tonsillectomy patients in a wide age range cohort. Tonsils are a major virus reservoir for distinct herpes and respiratory viruses without a positive association with tonsillar disease or respiratory symptoms.

Assessment of Friedman Classification by Measuring Actual Tonsil Size During Surgery

Background and Objectives: Adenotonsillar enlargement is a common cause of pediatric illnesses, including obstructive respiratory disease and recurrent airway infection. The current tonsil grading systems evaluate tonsil size, but the correlation with actual tonsillar size in a clinical setting has not been established.Materials and Method: Between May and July of 2018, we recruited 31 children who underwent adenotonsillectomy with no major craniofacial abnormalities. The actual size of the palatine tonsils, the long (L1) and short (S1) axes of the tonsil beyond the anterior pillar, and the real axes (L2 and S2) after tonsil extraction from the fossa were measured during surgery. Adenoid size was determined by measuring the adenoid-nasopharynx (AN) ratio through lateral view x-ray of the neck.Results: Though S1 was related to the Friedman scale (p<0.001), measured real axes were not (L2: p=0.058, S2: p=0.056). Also, adenoid size and AN ratio did not relate statistically to the Friedman scale (p=0.565). One of the measured real tonsil size parameters (S2) was related to AN ratio (p=0.048).Conclusion: For pediatric patients undergoing tonsillectomy and adenoidectomy, the Friedman grading scale based on physical examination may not reflect the actual size of the tonsils. Therefore, for children with obstructive sleep disorder or recurrent tonsillitis, intraoperative measurement of tonsil size can be helpful.

Assessment of Tonsil Volume With Transcervical Ultrasonography in Both Children and Adults

OBJECTIVES

To investigate the success of ultrasonography (USG) in the objective measurement of palatin tonsil volume in both children and adults and to compare those results with clinical findings.

METHODS

Eighty-five patients, who were scheduled to undergo tonsillectomy with the indications of recurrent tonsillitis and obstructive sleep apnea syndrome, were included in the study. The tonsil grades of the patients were recorded according to the Friedman tonsil grading. The tonsil size and volume were measured with transcervical USG. After tonsillectomy, the volumes of the tonsils were calculated by the displacement method. The correlation between the obtained data was evaluated. In all analyses, P < .05 was accepted as a statistical level of significance.

RESULTS

Fifty children and 35 adults were included in the study. In children, the mean actual volume ± SD of 100 tonsils was measured as 3.5 ± 1.45 mL, and the USG volume was 3.67 ± 1.59 mL; a high correlation was found between both methods (r = 0.842; P < .05). In adults, the mean actual volume of 70 tonsils was measured as 5.15 ± 2.25 mL, and the USG volume was 5.71 ± 2.98 mL; a moderate correlation was found between the methods (r = 0.589; P < .05). In children, a moderate correlation was found between the Friedman grading and the USG (r = 0.532; P < .05), and actual (r = 0.549; P < .05) tonsil volumes. In adults, a low correlation was found between the Friedman grading and the USG (r = 0.363; P < .05) and actual (r = 0.384; P < .05) tonsil volumes.

CONCLUSIONS

Ultrasonography is a useful, accessible, and noninvasive imaging method for objective measurement of tonsil volume in adults and children.

Guidelines of the French Society of Otorhinolaryngology. Role of the ENT specialist in the diagnosis of childhood obstructive sleep apnea-hypopnea syndrome (OSAHS). Part 1: Interview and physical examination

OBJECTIVES

To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This article focuses specifically on medical history and physical examination.

METHODS

A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group.

RESULTS

At the end of the process, guidelines were established and graded regarding the following points: interview and analysis of the various interview scores recommended in the literature; clinical examination with awake upper-airway endoscopy; and indications for referral to non-ENT specialists.

Asthma and obesity as predictors of severe obstructive sleep apnea in an adolescent pediatric population

OBJECTIVE

To study a cohort of children referred for full-night polysomnography (PSG) due to suspicion of obstructive sleep apnea (OSA). We examined the relationship between asthma, obesity, and severe OSA (sOSA).

METHODS

We performed a retrospective case control analysis of children, ages 9 to 17 years, who underwent full-night PSG. The primary goal was to determine the association between asthma, obesity, and sOSA (apnea-hypopnea index ≥10). We used multiple logistic regression analysis to estimate these associations after controlling for covariates. A P value of ≤.05 was considered significant.

RESULTS

The study included 367 children (mean [standard deviation] age 14 years (1.7), 56% male, 43% Hispanic). The prevalence of asthma was 188 of 367 (52%); obesity was 197 of 367 (54%); and sOSA was 109 of 367 (30%). sOSA was less likely in asthmatics (coefficient = -0.59; standard error [SE] = 0.23; P = .01; odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.34 to 0.88) and more likely with obesity (coefficient = 0.89; SE = 0.24; P < .001; OR = 2.4; 95% CI = 1.5 to 3.9). The presence of asthma reduced the likelihood of sOSA by an average of 14% among obese patients and 9% among nonobese patients. These associations held even after controlling for age, sex, race, income, and tonsillar hypertrophy.

CONCLUSION

The presence of asthma reduced, whereas obesity increased the likelihood of sOSA among a large cohort of older children referred for PSG. These relationships were additive. Further research is indicated regarding these relationships.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:812-817, 2020.

Common Pediatric Airway Disorders

Pediatric airway disorders may be congenital (anatomical) or acquired (infectious) and may involve the upper, lower, or entire airway, with obstruction being a common feature. The pathophysiology of upper airway obstruction in infants, children, and adolescents is distinctly different due to the anatomic differences that evolve with growth. Accordingly, clinical presentation and consequences of airway obstruction vary by age. This article reviews the common upper airway disorders by age with a review of classic presentation, recommended diagnostic steps, and management considerations for the general pediatrician. [Pediatr Ann. 2019;48(4):e162-e168.].

Nasopharyngeal Width and Its Association With Sleep-Disordered Breathing Symptoms in Children

Objectives

Although adenotonsillar hypertrophy is the main cause of sleep-disordered breathing in children, surrounding anatomic factors, such as the width of the nasopharynx, can affect upper airway patency. However, there have been no reports of the association of nasopharyngeal width with sleep-disordered breathing in children. This study was undertaken to measure nasopharyngeal width in children undergoing adenotonsillectomy for sleep-disordered breathing and to investigate the clinical implications of this factor.

Methods

This was a retrospective study with a follow-up period of 1 year, performed at a tertiary referral center. We reviewed the operative records of children who underwent adenotonsillectomy at our center for symptoms of sleep-disordered breathing, such as snoring, apnea, and mouth breathing. The nasopharyngeal width was measured immediately before adenotonsillectomy, which was performed under general anesthesia with a microscopy-assisted mirror view. Adenotonsillar hypertrophy was graded on a four-point scale, and symptoms of sleep-disordered breathing were evaluated by using the Korean version of the Obstructive Sleep Apnea-18 questionnaire before and after surgery. The relationships between the average nasopharyngeal width and patient age and sex, adenotonsillar hypertrophy, and the Korean version of the Obstructive Sleep Apnea-18 score were analyzed.

Results

The study included 549 children (343 boys) with a mean age of 6.0 years (range, 2 to 11 years). The average nasopharyngeal width was 11.9 mm (range, 7.0 to 18.0 mm) and increased with age (range, 11.2 to 13.3; β=0.264; P<0.001). At 1 year after surgery, children with a greater nasopharyngeal width at the time of surgery exhibited additional improvements in symptoms of obstruction relative to those at 1 month after surgery.

Conclusion

The average nasopharyngeal width in children is approximately 11.9 mm and exhibits a slight increase with age. The width of the nasopharynx may be a factor associated with the degree of improvement in symptoms of sleep-disordered breathing after adenotonsillectomy.

Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population

Objective

To determine the prevalence of respiratory complications in the early postoperative period of children with sleep apnea who required adenotonsillectomy at a tertiary pediatric hospital and to establish recommendations for postoperative monitoring.

Methods

Retrospective cohort study of children with obstructive sleep apnea (OSA) diagnosed by polysomnogram (PSG), who underwent adenotonsillectomy for treatment of OSA. The prevalence of respiratory complications in the first 24 postoperative hours was measured. Patients with craniofacial malformations, obesity, and severe cardiovascular comorbidities were excluded. The prevalence of postoperative respiratory complications was compared with the severity of OSA according to the Apnea Hypopnea Index (AHI) and NADIR. All data were taken in patients residing in Bogotá city, Colombia, at 2.640 meters above sea level (m.a.s.l).

Results

Between May 2014 and February 2017, 167 patients (108 males) required adenotonsillectomy for OSA, with an age range of 1 and 15 years (mean 5.3 years +/- 2.7). The prevalence of postoperative respiratory complications was 3.59% (6/167). There was a statistically significant relationship between the presence of respiratory complication and AHI greater than 44/h (p <0.04). There was an inverse correlation between the AHI and NADIR values. Risk groups of patients younger than 3 years and NADIR less than 70% had a higher prevalence of respiratory complications; however, this correlation was not statistically significant (p <0.08 and 0.89, respectively).

Conclusions

The prevalence of respiratory complications in OSA patients undergoing adenotonsillectomy in high altitudes is similar to that reported in other heights. Preoperative AHI greater than 44/h could be considered a risk factor for early respiratory complication. We suggest ambulatory management after 6 hours in Postanesthetic Care Unit (PACU) observation in patients older than 3 years, with AHI less than 44/h and NADIR greater than 70% in altitudes higher than 2.500 m.a.s.l. Further research must be done to confirm this hypothesis.

Intranasal Budesonide and Quality of Life in Pediatric Sleep-Disordered Breathing: A Randomized Controlled Trial

Objective

To study the efficacy of budesonide nasal spray on the health-related quality of life and symptoms among children with sleep-disordered breathing.

Study Design

Randomized, parallel, double-blind, placebo-controlled trial.

Setting

Tertiary referral center.

Subjects and Methods

Sixty children (ages, 4-10 years) who were referred because of snoring and/or apneas for >3 months were included between January 2015 and June 2016 and randomized in a double-blind design to treatment with 64 μg/mL of budesonide nasal spray (n = 30) or placebo nasal spray (n = 30) twice daily for 6 weeks. The primary outcome measurement was the change in the mean OSA-18 total score from baseline. Other variables examined were individual OSA-18 domains, a visual analog scale for quality of life, symptoms (snoring, apneas, and nasal obstruction), and adenoid and tonsil size. The trial was investigator initiated and not sponsored by the pharmaceutical industry.

Results

Fifty-five children completed the trial. An intention-to-treat analysis revealed a significantly greater improvement in the mean OSA-18 total score after treatment with budesonide than placebo (19.5 vs 7.5, P = .0014). Intranasal budesonide also improved 2 OSA-18 domains (sleep disturbance, caregivers’ concerns), the visual analog scale score for quality of life, as well as snoring, apneas, and nasal obstruction. No serious adverse events were reported that could be linked to the treatment.

Conclusion

Among children with sleep-disordered breathing, 6 weeks’ treatment with intranasal budesonide significantly improved quality of life and symptoms as compared with placebo nasal spray.

Ultrasonographic assessment of tonsillar volume in children

OBJECTIVES

Adenotonsillar hypertrophy in children is the most common anatomical abnormality associated with obstructive sleep apnoea. Perioperative complications associated with adenotonsillectomy are more common in children with severe obstructive sleep apnoea. An objective preoperative method to determine the size of tonsils is missing. This study assessed the validity of ultrasound as a tool for measuring tonsillar size in children.

METHODS

Single-institution prospective study of twenty-six children aged 2-6 years who underwent elective bilateral tonsillectomy. Trans-cervical ultrasonographic assessment of tonsillar size prior to tonsillectomy operation was performed. We assessed correlation of ultrasonographic and actual tonsillar volume.

RESULTS

A total of 52 tonsils from 26 patients were measured. Actual and ultrasonographic mean tonsillar volume (±SD) was 3.9 (±2.1) ml and 3.6 (±2.5) ml, respectively (P = 0.24). Ultrasonographic and actual measurements correlated well (r = 0.89).

CONCLUSIONS

This is the first study to show that ultrasound is a suitable objective method for determining tonsillar volume in paediatric patients. Preoperative ultrasound assessment of tonsillar anatomy and size may be an additional and suitable, objective method in the development of a risk stratification system in children with obstructive sleep apnoea undergoing tonsillar surgery.

Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study

BACKGROUND

Adenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20-40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB.

METHODS

A retrospective observational cohort study was undertaken at the Stollery Children's Hospital. Patients 3-17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen's kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated.

RESULTS

Five hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312-0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33-0.55]) between DISE and in-office clinical assessment.

CONCLUSIONS

This is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.

Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3-6 year old children undergoing adenotonsillectomy

INTRODUCTION

Adenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3-6 years with caregiver-reported symptoms.

METHODS

Children 3-6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.

RESULTS

The cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = -0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.

CONCLUSION

Subjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3-6 years of age undergoing adenotonsillectomy.