Adenotonsilotomia-OSAS (1)

7/30/2019 Adenotonsilotomia-OSAS (1)

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Annals ofOlolo^y. Rh inohgy & Laryngology 119(8):5O6-513. 2010 Annals PublisHing Company. All rights reserved.

Outcome of Adenotonsillectomy for Obstructive SleepApnea Syndrome in ChildrenJin Ye, PhD; Hui Liu, PhD; G e-hua Zhan g, PhD; Peng Li, PhD ; Qin-tai Yang, PhD ;Xian L iu, PhD; Yuan Li, PhD

Objectives: We evaluated the outcome of adenotonsillectomy for obstructive sleep apnea syndrom e (OSA S) in childrenusing polysomnography (PSG) data and a quality-of-life (QOL ) instrument.Methods: We enrolled children (4 to 14 years of age) who had OSAS diagnosed by overnight PSG and who underwentboth adenoidectomy and tonsillectomy between January 2003 and February 200 8. All of them had completed postopera-tive PSG and a paired Obstructive Sleep Ap nea 18-Item Quality-of-Life Qu estionn aire (OS A-18 ) survey. The statisticalanalyses were performed with a statistical software package.Results: The study included 84 children with a mean age of 7.1 years. The m ean preopera tive apne a-hyp opne a index(AHI) for the study population was 24.6, and the mean postoperative AHI was 3.8 episodes per hour. The percentage ofchildren who had normal PSG parameters after adenoton sillectomy ranged from 69 .0% to 86.9 % because of fluctuationof the criteria used to define OSAS. Nine children (30%) with severe preoperative OSAS had persistent OSAS (an AHIof at least 5) after surgery. Improvements in OOL were comparable in the cured and not-cured groups (p > 0.05). Riskfactors for persistent OSAS were obesity and a high preoperative AHI, on multiple logistic regression analysis.Conclusions: Adenotonsillectomy is associated w ith improvem ents in PSG, behavior, and OO L in children with OS AS .However, it may not resolve OSAS in all children. The efflcacy and role of additional therapeutic options require morestudy.Key Words: adenoidectomy, child, obstructive sleep apnea syn drom e, polysomnograph y, quality of l ife, tonsillectomy.

INTRODUCTIONObstructive sleep apnea syndrome (OSAS) isa common condition in children and is associatedwith potentially long-lasting cardiovascular,'^ neu-robehavioral,'''* and soma tic grow th consequen ces.^Given the fact that the most common cause of O SASin children is adenotonsillar hy pertrophy, adenoton-sillectomy has been widely accepted as the first lineof treatment. Although previous reports have showna significant reduction in respiratory abnormalitiesand arousal index after surgery, persistence of ab-normal polysomnography (PSG) findings is report-ed in approximately 20% to 40% of cases.^""^ The

effectiveness of adenotonsillectomy and the majordeterminants of postsurgical outcom e have not beencritically delineated.The outcome of adenotonsillectomy for OSAScan be evaluated on the basis of objective evidenceprovided by preoperative and postoperative PSG.At present, PSG is the most accurate and compre-hensive method for the diagnosis and quantification

of OSAS in children. However, it is expensive andtime-consuming and is often unavailable. These fac-tors have limited the sample sizes used in publishedstudies of the outcome of adenotonsillectomy forOSAS evaluated by PSG. Furthermore, quality-of-life (QOL) assessment is increasingly recognizedas an important health-related outcome measure inclinical medicine. Although a long-term improve-ment of QOL after adenotonsillectomy has beenproved," the correlation between a decline in thePSG index and changes in the QOL score is lesswell documented.To shed m ore light on the outcome of adenoton sil-lectomy for pdiatrie OS AS , in the present study weused data from preoperative and postoperative PSGin combination with a paired O bstructive Sleep Ap-nea 18-Item Quality-of-Life Questionnaire (OSA-18) survey. Moreover, the correlation between PSGamelioration and change in OSA -18 score was eval-uated. The goal was to provide a com prehensive as -say of surgical outcom es and to identify variables thatpredispose children to persistent OSA S after surgery.

From the Departm ents of Sleep Study and Otolary ngolo gy-H ead and Neck Surgery (Y e, Zhan g, P. Li, Yang, X. Liu, Y. Li) and Respira-tory Diseases (H . Liu), Third Affiliated Hospital of Sun Yat-sen University, Gua ngzho u, C hina.Correspondence: Jin Ye, PhD , Dept of Otolaryng ology -Head and Neck Surgery, Sleep Study Center, Third Affiliated Hospital of SunYat-sen University , No. 600,Tianhe Street, Guangzhou, Guangdong, China 510630.

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Ye er ai. Adenotonsillectomyfo r Sleep Apnea 50 7METHODS

POPULATION AND STUDY DESIGNApproval for the present study was obtained fromthe Institutional Review Board of Sun Yat-sen Uni-versity. Parents or caregivers were asked to com-

plete an informed consent document before enroll-ment in the study.First, we identified qualified cases from the medi-cal record database in our hospital. All children whounderwent both adenoidectomy and tonsillectomyfrom January 2003 to February 2008 were consid-ered for enrollment. Children of 4 to 14 years of agewere included if they had had signs and symptoms ofa sleep disturban ce, including snoring, mouth b reath-ing, and witnessed apn ea, of at least 3 m on ths ' dura-tion and if they had OS AS as evidenced by p reoper-ative PSG ev aluation. The exclusion criteria were anage outside the range of 4 to 14 years, an Am ericanSociety of Anesthesiologists physical status score ofmore than 3, concomitant surgery, genetic disord ers,prematurity, craniofacial abnormalities. Down syn-drome, congenital heart disease, bronchopulmonarydysplasia, cerebral palsy, cystic fibrosis, neurom us-cular diseases, previous adenotonsillectomy or otherairway surgery procedures, and contraindications togeneral anesthesia. The qualified children were en-rolled in our study and successively followed up be-tween 2004 and 200 9. The children w ere asked toreturn for a postoperative rvaluation including an

overnight sleep study and an OSA-18 survey.All of the included children underwent adenoton-sillectomy under general anesthesia. The anestheticand surgical techniques of adenotonsillectomy didnot vary greatly during the study period. Tonsillartissue was removed by dissection or by the guillo-tine rnethod, and hemostasis was obtained with bi-polar electrocautery. Adenoid tissue was removedby use of a microresecting instrument under endos-copy. At our institution, adenotonsillectomy is rou-tinely performed by professors or senior attendingphysicians, and the large number of adenotonsillec-tomies performed has resulted in a fairly standard-ized surgical technique.

DATA COLLECTIONFor all studied patients, data were extracted fromthe medical records by 2 specialists using a speciallydesigned case report form. This included a manualreview of the laboratory data, surgical records, anes-thesia forms, treatment records, progress notes, andnursing note s. All of the forms were checke d by an-other researcher for errors. Th en, the data were dou -ble-entered manually into a Microsoft Excel master

sheet to build our database. The variables recorded

on the case report form and pertinent definitions aredescribed below.Baseline Characteristics. Demographic data in-cluded age, sex, height, weight, and pertinent his-tory. Body mass index (BMI) was converted into a

B M I z score according to the normal values of Chi-nese children. '2 Children were considered obese ifthe ir BM I z score was over 1.946 (corresponding tothe 95th percentile). For each child, the degree ofadenotonsillar hypertrophy was assessed with an en-doscope by the otolaryngology clinicians within aweek before surgery. Tonsil size was graded on a4-po int sca le. For grad e 1, the tonsils were lying lat-eral to the tonsillar fauces; for grad e 2, at the level ofthe fauces; for grade 3, medial to the fauces but notto the midline; and for grade 4, touching at the m id-line. The deg ree of adenoid obstruction was evaluat-ed as follow s: grade 1, no or minim al adeno id tissue(0 % to 25% obstruction); grade 2, a small amountof adenoid tissue (26% to 50% obstruction); grade3 , a large amount of adenoid tissue that might causesymptomatic nasa l obstruct ion (5 1% to 75% o b-struction); and grade 4, obstructing adenoid tissue(76% to 100% obstruction).Sleep Study. Overnight PSG was performed at theSleep Study C enter in the Third Affiliated Hosp italof Sun Yat-sen University by measuring the follow-ing standard neurophysiologic and respiratory sig-nals: electroencephalogram with central, anterior,

and occipital leads; electro-oculograms; submentaland diaphragmatic electromyogram with externalelectrodes; and heart rate and rhythm recorded byelectrocardiogram. Airflow was recorded with a na-sobuccal thermistor. Nasal pressure was measuredwith a nasal cannula connected to a pressure trans-ducer. Chest wall excursion was measured by respi-ratory inductive plethysmography. Oxygen satura-tion was measured by pulse oximetry set at a 2-sec-ond averaging time. Body position was noted, anddigital videotaping with sound recording was per-formed throughout the night.The following PSG parameters were recorded:apnea-hypopnea index (AHI), defined as the aver-age number of obstructive apneas and hypopneasper hour of total sleep time, the oxygen saturationas measured by the pulse oximetry (pulse oxygensaturation; SpO2) nadir, and the percentage of timethe oxygen saturation was lower than 90% recordedthroughout the sleep study. Obstructive apnea wasdefined as a total absence of airflow through themouth and nose with continued chest and abdomi-nal movement for at least 2 respiratory cycles. Hy-popneas were defined as a decrease in nasal flow of

at least 50% with a corresponding decrease in SpO2


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508 Ye et al, Adenotonsillectomy for Sleep Apneaof at least 4% or arousal. We defined OSAS as anAHI of at least 5. An AHI score of more than 5 andless than 10 was considered mild OSAS; at least 10but less than 20 , moderate O SA S; and 20 or higher,severe disease.'^ A sleep medicine specialist inter-preted the PSG results.

QOL Survey in Children With OSAS. The caregiv-ers were asked to complete the OSA-18 survey be-fore and after surgery. The first survey was complet-ed before PSG, and the second survey, during thefollow-up visit after PSG. This survey comprises 18items in the 5 domains of sleep disturbance, physicalsuffering, emotional distress, daytime p roblems, andcaregiver concerns. The domains of emotional dis-tress and daytime problems contain 3 items, and theother domains contain 4. A point scale is used, rang-ing from 1 (none of the time) to 7 (all of the tim e), tograde the relative severity of the problems addressedin each item. The total score and the domain scoreswere recorded. Subtracting the mean postoperativescore from the mean preoperative score derived thedifference score.STATISTICAL ANALYSIS

In a study by M itchell and Kelly,^ the frequenciesof surgical cure (AHI score of less than 2 episodesper hour) in obese and normal-weight children were24% and 72%, respectively. The required samplesize to detect such a difference between obese andnormal-weight children in the present study, assum-ing an average frequency of resolution of OSAS of55% with an 80% power at the 5% level, was 18children per group.Continuous variables are presented as a mean SD or range, and categorical variables are presentedas a number (and pe rcent). The change index of AHIwas calculated as [(Preoperative AHI Score - Post-operative AHI Score)/(Preoperative AHI Score)].The Wilcoxon signed-rank test was used to comparethe mean values of PSG parameters before and af-ter surgery. A paired i-test was used to evaluate thesignificance of differences between the preoperativeand postoperative O SA-18 surveys. Differences be-tween two groups were assessed with y} statisticsfor categorical variables and with Student's /-test forcontinuous variables. Nonpararnetric analysis usingthe Mann-Whitney U test was used for data withnonnormal distributions. Comparisons among mul-tiple groups were performed with the Kruskal-Wal-lis test. A Pearson correlation was used to assess themean preoperative and postoperative OSA-18 totalscores with the preoperative and po stoperative A HIscores. Potential risk factors were first evaluatedwith univariate analysis, followed by multivariate

logistic regression with the occurrence of postop-

erative respiratory complications as the dependentvariab le. The threshold for statistical significancewas a p value of less than 0.05. All of the statisticalanalyses were performed with a statistical softwarepackage (SPSS for Wind ows, version 11.0, SPSSInc, Chicago, Illinois).RESULTS

STUDY POPULATIONThe computer identified 341 children who un-derwent both tonsillectomy and adenoidectomy forOSAS in our hospital from January 2003 to Febru-ary 2008. Of 308 children of 4 to 14 years of age,224 children had completed preoperative PSG and188 children with a diagnosis of OSAS met the in-clusion criteria. Five children were excluded be-cause of a comorbid condition (cerebral palsy and

craniofacial abnormalities in 1 each) or concomitantsurgery (3 cases). A total of 183 children w ith OSA Sinitially constituted our study cohort. On follow-up,63 children were lost and 36 children without pairedPSG or OSA-18 data were excluded.Therefore, a population of 84 children were en-tered into the final ana lysis. The m ean age at the timeof operation was 7.1 3.2 years, and 59 patients(70.2%) were male. Forty-nine children (58.3%)were between 4 and 8 years, 26 children (31.0%)were between 8 and 12 years, and 9 children (10.7%)were between 12 and 14 years. Regarding the tonsil-lar size, 39 cases (46.4%) were classified as grade 3or 4, and 68 children (81.0%) had obvious adenoidhypertrophy of grade 3 or 4.According to the preoperative age- and sex-cor-rected BMI z score, 59 children (70.2%) were ofnormal weight, 7 (8.3%) were overweight, and 18(21.4%) were obese. The mean BMI z scores of thetotal cohort were 1.1 1.9 and 1.2 1.7 at baselineand follow-up, respectively (p > 0.05). For the 18obese children, the difference in BMI z score at fol-low-up compared with that at baseline was not no-

table (2.3 1.2 versus 2.4 1.1; p > 0.05 ).PERSISTENT OSAS AETER SURGERYThe mean preoperative AHI score was 24.6 17.3 in the 84 children. Before operation, 45 cases(53.6%) were classified as moderate OSAS and 30patients (35.7%) had severe OS AS . The m ean inter-val between preoperative PSG and adenotonsillec-tomy was 11 days (range, 2 to 34 days). The meaninterval between adeno tonsillectomy and postopera-tive PSG was 19 months (range, 18 to 23 months).The mean interval between preoperative and post-operative PSG was 20 months (range, 18 to 24months).


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Ye et al, Adeno tonsillectomy for Sleep Apnea 509TABLE 1. RESPIRATORY PARAMETERS AND SLEEPARCHITECTURE BEFORE AND AFTERADENOTONSILLECTOMY IN 84 CASES OFPEDIATRIC OSAS

100

Parameter Preopera tive Postoper ative pO b s tr u ct iv e A H I 2 4 . 6 t 7 . 3 3 .87 .9


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510 Ye et al, Adenotonsillectomy for Sleep ApneaT A B L E 4 . P O T E N T I A L P R E D I C T O R S O F S U R G I C A L C U R E (AHI S C O R E O F LESS THA N 5) ON UNIVARIATELO G ISTIC R EG R ESSIO N A N A LY SIS

CharacteristicsA ge (y ; m ean)Male genderObesi ty at basel ineAdenoids grade >3Tonsils grade >3Snor ing at basel ineEvidence of allergic rhinitis or as thmaPositive family history for SD BPositive family history for allergyPositive family history fo r obesityAHI before surgery (mean SD)Pers is tence of snoring after surgeryRegrovvth of adenoid tissue after surgery

OR odd.s ratio; CI confidence interval;

Cured (n = 73)7.1

51 (69.9%)14(19.2%)59 (80.8%)24 (32.8%)55 (75.3%)10(13.7%)6 ( 8 . 2 % )

12(16.4%)13(17.8%)24.1 10.1

9 ( 1 2 . 3 % )7 (9.6%)

Not Cured (n = II)12

8 (72.7%)4 (36.4%)9 ( 8 1 . 8 % )5 (45.5%)8 (72.7%)2 ( 1 8 . 2 % )1 (9.1%)2 ( 1 8 . 2 % )2 ( 1 8 . 2 % )29.9 15.02 ( 1 8 . 2 % )1 (9.1%)

SDB -.sleep-disordered brea thing.

Unadjusted OR(95% C I)0.90 (0.24 to 2 .80)0.72 (0.2 to 1.99)21.0(11.1 to 34.8)0.76(0.31 to.2.57)1.62 (0.37 to 9.36)0.66 (0.36 to 1.30)1.55 (0.59 to 7.30)0.43 (0.23 to 1.92)0.63 (0.30 to 2 .40)0.32 (0.10 to 3.27)15.1 (12.0to21.2)1.56 (0.68 to 7.79)0.28 (0.13 to 1.53)

PNSNS

0 .0 5 ) .RISK FACTORS FO R PER SISTEN T O SA S A FTERSU R G ER Y

Resolution of OSAS (surgical cure), defined asa postoperative AHI score of fewer than 5 episodesper hour, occurred in 73 children (86.9% ) after ade-notonsil lectomy in our cohort. Persistent OSA S pre-sented in II children (13.1% ). As shown in Table4, there were no statistically significant differenc-es between the two groups with respect to age, sex,adenoid size, or a positive family history of allergyor OSAS (p > 0.05). In summary, the children withpers is tent OSA S were m ore obese and had more se-vere OSA S before surgery. They also had h igher in-cidences of tonsillar hypertrophy, a history of aller-gic rhinit is or asthma, and persistent snoring afteradenotonsil lectomy. A multiple logistic regressionanalysis was performed using the 5 clinical factorsidentified from the univariate ana lysis. Th e resultsshowed that only obesity (odds ratio [OR], 3.239;9 5% confidence interval [95% CI], 1.759 to 7.893;p - 0.004) and preoperative AHI score (OR, 6.151;95% CI, 3.836 to 20.637; p < 0.001) were signifi-

cant!}' related to the incidence of persistent OSASafter adenotonsil lectomy.IM PR O V EM EN T'S IN Q O L A FTER SU R G ER Y

The mean interval between the firs t OSA-18 sur-vey and surgery was 12 days (range, 2 to 39 days).The mean interval between surgery and the sec-ond survey was 20 months. The mean interval be-tween the two surveys was 21 months (range, 18 to25 mo nths) . The O SA-18 total and dom ain scoresbefore and after adenotonsil lectomy for 84 childrenwith OSA S are presented in Table 5. The mean totalOSA-18 score was 77.6 before surgery and 32.5 af-ter surgery (p < 0.001). Before operation, the meantotal survey and the individual domain scores werenot s ignificantly different between the two groups,and the same was true after surgery (p > 0.05 forall). In both groups, the scores for the total and alldomains showed an obvious decrease after surgery.Improvements in QOL as shown by change scores(preoperative score m inus postoperative score) werecom parable in the two groups (p > 0.05).C O R R E L A T I O N B E T W E E N P S G A N D O SA -18 SC O R ES

The preoperative AHI scores had a poor correla-tion with the preoperative total OSA-18 scores (r =0.05), and the same poor correlation was seen be-tween the postoperative AHI and the postoperativetotal OSA-18 scores (r = 0.11). Neither the reduc-tion of AHI scores (r = 0.14) nor the change indexof the AHI (r = 0.10) had a correlation with the totalOSA-18 change scores .S U B G R O U P S T U D Y O F O B E S E A N D N O R M A L - W E I G H TC H I L D R E N

To further clarify the effect of obesity in persis-tent OSAS after adenotonsil lectomy, we chose 20normal-weight children with comparable preopera-


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Ye et al, Adeno tonsilleclomy for Sleep Apnea 511TABLE 5. IMPROVEM ENTS IN QUALITY OF LIFE AIT'ER ADENOTONSILLECTOMY FOR PEDIATRIC OSASACCORDING TO SURGICAL CURE (AHI SCORE OF LESS THAN 5)

OSA-1S CategorySleep disturbancePhysical .symptomsEmotional symptomsDaytime functionCaregiver concernsTotal

Initial20.4 6 .215.2 9.011.4 4.711.0 5.5 .19.6 5.977.6 19.0Data are mean SD OSA-18 scores.*Comparison of meantComparison of mean^Comparison of mean

Cured (n = 73)Final6.1 5.8

7.8 4.96.7 5.35.3 3.77.0 5.232.5 21.0initial survey scores between two groupsfinal survey scores between two gro ups.

Change14.3 6.07.4 5.94.7 2.65.7 4.7

12.5 5.744.7 23.1, p>0.05 for all.p> 0.0 5 for a ll .final survey score with initial survey score in each group, p < 0.05iiComparison of mean change scores (preoperative score minus

Initial*2 1 . 4 7 . l16.3 7.711.7 5.410.2 4.720.9 7.480.5 20.5

for all .postoperative score) between two groups

N o t C u r e d (n =11)FinalU6.2 5.38.2 6.06.4 5.35.1 4.57.1 4.933.0 19.7

p> 0.0 5 for a l l.

Cliange15.2 7.08.1 6.25.2 5.45.1 4.9

13.7 8.147.5 25.2

tive AHI values for a subgroup study. There were nosignificant differences between the obese and nor-mal-weight children regarding age, gender, size ofadenoids or ton sils, or preoperative AHI value (p >0.05). The frequency of a postoperative AHI scoreof less than 1 episode per hour was 50% (n = 10) innormal-weight children and 33.3% (n - 6) in obesesubjects (p < 0.01). The rate of surgical cure (AHIscore of less than 5) in obese children (50%; n =9) was obviously lower than that in normal-weightchildren (65 % ; n = 13), independent of the initial se-verity of the OSAS. In contrast, the improvementsin AHI and OSA-18 scores were not signilficantlydifferent between the two groups (p > 0.05).

DISCUSSIONThis study is one of several to date uing thechange between preoperative and postoperative PSGfindings as the principal outcome measure doncern-ing adenotonsillectomy for pdiatrie OS AS . We ana-lyzed outcome on the basis of a variety of diagnosticcriteria for residual OSAS. The rate of surgical curewas 86.9% if an AHI score of less than 5 episodesper hour was used to define resolution of OSAS. Ifa strict criterion such as an AHI score of less thanI episode per hour was used to define normal, then

31.0% of the children had persistent OSAS afteradenotonsillectomy. Thus, our results further con-firmed previous findings that adenotonsillectomymay not be sufficient to completely eliminate prob-lems of abnormal breathing during sleep, althoughchildren with OSAS showed significant improve-ment in respiratory parameters after surgery.FACTORS RELATED TO PERSISTENT OSAS AFTERSURGERY

As described, the cure rate of adenotonsillectomyranges widely, depending on differences in the en-rolled populations and PSG criteria for OSAS.'^-'^In a study by Tauman et al,'" normalization of sleep

parameters after adenotonsillectomy (AHI score of1 or less) for OSAS was found in only 25% of chil-dren. However, more than 50% of the children in-cluded in their study were obese, and 71 % had aller-gies. After excluding children with obesity, allergies,and craniofacial, neuromuscular, and genetic prob-lems, Mitchell'-' found normalization (AHI score ofless than 5) in 82% (n = 79) of children after ade-notonsillectomy.AHI. Consistent with previous findings,^'"^'-^'^the present study demonstrated that the initial sever-ity of a sleep disorder was associated with the per-sistence of OSA S after surgery. None of the childrenwith a preoperative AHI score of less than 10 hadpersistent OSAS after surgery (AHI of at least 5). Incontrast, 9 of 30 children (30%) with a preoperativeAHI score of greater than 20 had persistent OSASafter surgery. Accordingly, Mitchell'^ found that 3children (12%) with moderate preoperative OSASand 13 children (36%) with severe preoperativeOSAS had persistent OSAS (AH of at least 5) afteradenotonsillectomy. Moreover, the reduction of AHIlevel after surgery was closely linked to the initialseverity of OSAS, a finding that is strikingly similarto other st ud ies .'"'^ We found that surgery can less-en the preoperative AHI level by 70% to 80% , inde-pendent of the initial severity of OSAS. Therefore,the residual 20% to 30% of airway obstruction aftersurgery may play a critical role in the decision ofwhether OSAS persists or not. Rather than residualdisease, persistent OSAS after adenotonsillectomymay be caused by a number of factors, such as al-lergic disease, adenotonsillar regrowth, and recur-rent rhinitis.Obesity. As reported, adenotonsillectomy can ob-viously ameliorate the abnormal PSG param eteis inobese children with OSAS and adenotonsillar en-

largement, but it may be more effective in nonobesesubjects.'^ Tauman et al'" assessed 110 children (1


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512 Ye et al. Adenoto nsillectomy for Sieep Apneato 16 years of age) and found that the cure rate (post-operative AH I score of less than 1 ) was 17% in obesechildren and 36% in nonobese childten. In anotherseries,'^ the postoperative AHI score was less than2 episodes per hour in 60% of nonobese participantsand 24 % of obese participants. Consistently, Mitch-ell and Kelly *^ reported a posto pera tive A HI score ofless than 2 episodes per hour in 72% of 39 normal-weight children (3.3 to 17 years of age) and in 24%of 33 obese children (3.1 to 15.6yearsof age).In thecurrent study, the surgical cure rate (AHI score ofless than 5) remained lower in obese children thanin normal-weight children, even after we controlledfor preoperative disease severity. Indeed, the impactof obesity on the outcome of surgery for OSAS re-mains a controversial issue. Studies by O'Brien etapi and Apostolidou et ap2 both demonstrated thatobesity does not necessarily predict an unfavorableoutcome of adenotonsillectomy for OSAS. In brief,adenotonsillectomy improves, but does not resolve,OSAS in the majority of obese children. The coin-cidence of obesity and OSAS would be expected topromote and exacerbate the severity of the systemicinflammatory response separately elicited by eachof these diseases, which is associated with a distinctand overall recognizable clinical phenotype.^^

Other Factors. In accord with previous reports,'^'-^age was not a predictor of residual OSAS after ade-notonsillectomy in the current study. It is reportedthat children under the age of 3 years may be at in-creased risk for residual upper airway obstruction af-ter surgery .9

In contrast to early studies,'^''^^'* persistent snor-ing at follow-up poorly correlated with persistentOSAS after adenotonsillectomy in the current study.Possibly, children without symptoms tend not to bebrought back for postoperative PSG because theyare judged to be well by their caregivers. This lossto follow-up may skew the results toward those chil-dren with persistent symptom s.QOL IMPROVEMENTDistinct improvements in QOL have been report-ed in pdiatrie OSAS after adenotonsillectomy, re-gardless of the severity of the disorder.^-'"*'25-27 inconcurrence with the findings of Stewart et a\,^^ theimprovement in QOL was nevertheless significant

for the entire cohort, and the changes in OSA-18scores were similar between the cured and noncuredgroups. Therefore, neither obesity nor the presenceof persistent OSAS after surgery tends to impair thebenefit that children with OSAS obtain from ade-notonsillectomy.A poor correlation between the severity of O SASand total OSA-18 scores on QOL survey has beenproved in most previous studies.^'^'^^ There is lim-ited information about the correlation between ame-lioration in PSG parameters and improvements inQOL. In the present study, the change of OSA-18scores was not parallel with either the preoperativeAHI score or the reduction of AHI scores. This find-ing indicates that PSG and the OSA-18 survey arerelated but complementary, since they assess differ-ent but associated constructs.

LIMITATIONSThere are limitations to our study. It was per-formed in a single-center background, and a ran-domized controlled design was not used. Addition-ally, there were no craniofacial and anatomic mea-sures studied for the children with OSAS. Other fac-tors, such as regrowth of adenoid tissue and a posi-tive history of allergy or of OSAS, may affect thesurgical outcome. It is likely that larger cohorts willbe needed to accurately evaluate the relative contri-butions of such potential risk factors to postsurgical

outcomes.CONCLUSIONS

In summary, although adenotonsillectorny forOSAS successfully improves the PSG parametersin the majority of children, obesity and severity ofOSAS may increase the risk of residual OSAS aftersurgery. Better indicators of persistent OSAS afteradenotonsillectomy in children should be identified.Increased awareness of the risk of residual OSASshould inform preoperative discussions and the ex-pectations that families develop before surgery. Al-though QOL instruments may have a role in identi-fying children who will develop persistent OSAS,postoperative follow-up PSG may be more practi-cal and consistent. For children with residual O SA S,the efficacy and role of additional therapeutic op-tions require more study.

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2OO4;I31:104-8.7. Guilleniinault C, Li K, Quo S, Inouye RN. A prospec-tive study on the surgical outcomes of children with sleep-dis-ordered breathing. Sleep 2004 ;27:95-l00 .8. Guilleniinault C, Li KK. Khramtsov A, Pelayo R, Marti-nez S. Sleep disordered breathing: surgical outcomes in prepu-bertal children. Laryngoscope 2004;l 14:132-7.9. Mitchell RB, Kelly J. Outcome of adenotonsillectomyfor obstructive sleep apnea in children under 3 years. Otolaryn-gol Head Neck Surg 2005; 132:681-4.

10. Tauman R, Gulliver TE. Krishna J. et al. Persistence ofobstructive sleep apnea syndrome in children after adenotonsil-lectomy. J Pediatr 2006:149:803-8.11. Baklassari CM, Mitchell RB. Schubert C, Rudnick EF.Pdiatrie obstructive sleep apnea and quality of life: a meta-analysis. Otolaryngol Head Neck Surg 2008; 138:265-73.12. Leung SS.C oleT J.T se LY.Lau JT. Body mass index ref-erence curves for Chinese children. Ann Hum Biol 1998:25:169-74 .13. Mitchell RB. Adeno tonsillectomy for obstructive sleepin children: outcome evaluated by pre- and postoperative poly-somnography. Laryngoscope 2007; 117:1844-54.14. Mitchell RB, Kelly J. Outcomes and quality of life fol-lowing adenotonsillectomy for sleep-disordered breathing inchildren. ORL J Otorhinolaryngol Relat Spec 2007;69:345-8.15. Brietzke SE, Gallagher D. The effectiveness of tonsillec-tomy and adenoidectomy in the treatment of pdiatrie obstruc-tive sleep apnea/hypopnea syndrome: a meta-analysis. Otolar-yngol Head Neck Surg 2006:134:979-84.16. Friedman M, Wilson M, Lin HC, Chang HW. Updat-ed systematic review of tonsillectomy and adenoidectomy fortreatment of pdiatrie obstructive sleep apnea/hypopnea syn-drome. Otolaryngol Head Neck Surg 2009; 140:800-8.17. Suen JS, Arnold JE , Brooks LJ. Adenotonsillectomy for

treatment of obstructive sleep apnea in children. Arch O tolaryn-gol Head Neck Surg 1995; 121:525-30.18. Costa DJ. Mitchell R. Adenotonsillectomy for obstruc-tive sleep apnea in obese children: a meta-analysis. OtolaryngolHead Neck Surg 2009; 140:455-60.19. Gozal D, Capdevila OS, Kheirandish-Gozal L. Metabolic

alteratiotis and systemic inflammation in obstructive sleep ap-nea among nonobese and obese prepubertal children. Am J Re-spir Crit Care Med 2008; 177:1142-9.20 . Mitchell RB, Kelly J. Outcotne of adenotonsillectomyfor obstructive sleep apnea in obese and normal-weight chil-dren. Otolaryngol Head Neck Surg 2007; 137:43-8.21 . O'Brien LM, Sitha S, Baur LA, Waters KA. Obesity in-creases the risk for persisting ob structive sleep apnea after treat-ment in children, hit J Pediatr Otorhinolaryngol 2006:70:1555-60 .22 . Apostolidou MT. Alexopoulos El, Chaidas K ,et al. Obe-sity and persisting sleep apnea after adenotonsillectomy inGreek children. Chest 2008; 134:1149-55.23 . Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D.Pdiatrie obstructive sleep apnea: complications, management,and long-term ou tcomes. Proc Am Thorac Soc 2008;5:274-82.24 . Nieminen P, Tolonen U , Lppnen H . Snoring and ob-structive sleep apnea in children: a 6-month follow-up study.Arch Otolaryngol Head Neck Surg 2000; 126:481-6.25 . Mitchell RB, Kelly J, Call E, Yao N. Quality of life af-ter adenotonsillectomy for obstructive sleep apnea in children.Arch Otolaryngol Head Neck Surg 2004; 130:190-4.26 . Elanary VA. Long-term effect of adenotonsillectomy onquality of life in pdiatrie patients. Laryngoscope 2003:113:1639-44.27 . Mitchell RB, Kelly J, Call E, Yao N. Long-term changes

in quality of life after surgery for pdiatrie obstructive sleep ap-nea. Arch Otolaryngol Head Neck Surg 2004; 130:409-12.28 . Stewart MG . Glaze DG , Friedman EM, Smith EO, Bau-tista M. Quality of life and sleep study findings after adenoton-sillectomy in children with obstructive sleep apnea. Arch Oto-laryngol Head Neck Surg 2005; 131:308-14.29 . Mitchell RB, Kelly J. Child behavior after adenotonsil-lectomy for obstructive sleep apnea syndrome. Laryngoscope2005;l 15:2051-5.


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