Abstract
This study aims to assess the improvement in quality of life and symptoms in paediatric obstructive sleep apnoea patients before and after adenotonsillectomy. From all paediatric patients who presented to our OPD with complaints of mouth breathing and snoring, a subset of patients fulfilling our inclusion criteria were selected and evaluated with PSQSRBD scale, quality of life (QoL) inventory and PSG level-III. Later37 patients who had moderate to severe OSA were selected for study and underwent adenotonsillectomy. They were further followed up postoperatively at 3 months and 7 months with PSQSRBD Scale and QoL inventory. The study cohort had 37 patients with moderate to severe OSA, with a mean age of 8yrs.The postoperative (mean of 3rd and 7th month) values of PSQSRBD Scale and QoL inventory values was significantly (p < 0.001) reduced compared to preoperative Values after adenotonsillectomy. There is statistically significant correlation between adenoid and tonsil size to the relief of symptoms (PSQSRBD SCALE values) and improvement of quality of life. In our study, surgical (adenotonsillectomy) intervention has significant effect in management of moderate to severe non syndromic paediatric OSA patients.
Keywords: Paediatric OSA, Adenotonsillectomy, PSQSRBD Scale, Quality of life inventory
Introduction:
Sleep disordered breathing (SDB) is a continuum of disorder that range from simple snoring (primary snoring) to Obstructive Sleep Apnoea (OSA). 10–21% [1] of children are estimated to have sleep disordered breathing, with prevalence of primary snoring being 8% and that of OSA 1–5% [2, 3].
OSA (OBSTRUCTIVE SLEEP APNOEA) is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction (hypopnoea) and/or intermittent complete obstruction (apnoea) that disrupts normal ventilation during sleep and normal sleep patterns. It is characterised by snoring, mouth breathing, daytime sleepiness, growth failure, cardiovascular dysfunction and neurocognitive and behavioural problems [4]. Complications include:
Cognitive and Behavioral Abnormalities like delirium [5]
Growth and Neurological Abnormalities.
Cardiovascular and Pulmonary complications.
It is a treatable cause of future metabolic disorders, neurological problems. An awareness and regular screening can help us identify and address this issue. Major cause of OSA in non syndromic paediatric children is hypothesised to be adenotonsillar hypertrophy [6, 7].
Mainstay of treatment for moderate to severe Paediatric OSA is surgery esp adenotonsillectomy [7] which is found to reduce symptoms and improve secondary outcomes of behaviour, quality of life and polysomnography findings. This study intends to assess the effectiveness of adenotonsillectomy in reducing symptoms and increasing quality of life in paediatric OSA patients.
Materials and Methods
This single institution prospective observational study was conducted between the period of July 2017 to August 2019 at Department of Otorhinolaryngology, JSS Medical College, JSSAHER, Mysore, Karnataka, India.
From all children between the age of 5–18 years who presented to our out-patient department with complaints of mouth breathing and snoring, we excluded children with acute upper respiratory tract infection, syndromic children and those with structural abnormalities of nose, palate and tongue.
Others were provisionally included in the study, and further evaluated for adenotonsillar hypertrophy (radiological or endoscopic evaluation) and with a 22 item Paediatric Sleep Questionnaire- Sleep Related Breathing Disorder(PSQSRBD scale)[8] and Generic Health Related Quality of Life Questionnaire(QoL scale) [9]. PSQSRBD scale is 22 item questionnaire duly filled by parents or caregivers and scored by examiner. Each of the 22 questions have ‘yes’, ‘no’ or ‘don’t know’ as a response. Each “yes” response is given 1 point and “no” response is given 0 points. Sum of yes and no responses (yes + no) divided by (yes + no− don’t know) will give the mean value scored between 0 and 1. Value of more than or equal to 0.33 is suggestive of patient suffering from higher risk of sleep related breathing disorder and was subsequently selected for the study. Generic health related quality of life was assessed under 4 domains: physical, social, emotional and school functioning using 20 item questionnaire. Each question can have a score of 0–4 according to response.
A subset of patients with moderate to severe OSA was selected and underwent a complete physical and demographic examination including height, weight, BMI and in addition polysomnography (PSG) level–III. BMI was calculated using standardised formula and any value within 85th percentile was considered normal. Level-III polysomnography was carried out on each subject and apnoea hypopnea index (AHI), oxygen de-saturation, etc. we have calculated as the (PSG) polysomnography parameters used to assess severity of OSA.
37 patients were diagnosed with moderate to severe OSA and were subjected to standard of care procedure that is adenotonsillectomy. Tonsillectomy was done by conventional dissection and snare method. Endoscopic Adenoidectomy was done either with microdebrider assistance or coblation assistance. All patients in the immediate 24 h post-operative period was monitored in the hospital and discharged on the following day. All patients were followed up at one week, three months and seven months post-operative period. All pre-operative values were considered as a baseline values. At 3 months and 7 months postoperative follow-up patients were further evaluated with PSQSRBD scale and Generic health related quality of life QoL scale.
Results
A cohort of 37 patients who had moderate to severe OSA according to PSQSRBD Scale and PSG level –III was selected for this study. Age wise distribution of our patients showed that more than 50% of our patients were between the age of 5 to 8 years (pre-school and school going children) Fig. 1, with mean age of 8.76 ± 3.39 years. Figure 1 Age distribution of study population.
Fig. 1.
Age wise distribution of study population
Our study population consisted of 16 females and 21 males participants. Age wise gender classification is as shown in Table 1.
Table 1.
Age wise gender classification
| Female | Female | Male | ||
|---|---|---|---|---|
| Count | % | Count | % | |
| Age category | ||||
| 5–6 | 6 | 37.5% | 7 | 33.3% |
| 7–8 | 5 | 31.3% | 4 | 19.0% |
| > 9 | 5 | 31.3% | 10 | 47.6% |
| Total | 16 | 100.0% | 21 | 100.0% |
Physical examination of all subjects including height, weight, BMI was calculated Table 2.
Table 2.
mean values of demographic parameters
| Mean | Standard deviation | |
|---|---|---|
| Age | 8.76 | 3.39 |
| Height cm | 125.08 | 13.31 |
| Weight Kg | 24.86 | 6.97 |
| BMI Kg/m2 | 15.64 | 1.97 |
Tonsil size and Adenoid size were the next important parameters studied. Majority of our patients, i;e 67.6% (25) of our patients had grade 3 tonsil table(3). Moreover, almost 60% of children with grade 3 and 4 tonsils were found between the age of 3–7 years.
Adenoid size assessment showed 73% (i. e 27) patients with grade 3 and 27% with grade 4 adenoid hypertrophy. 6/10 of our grade 4 adenoid patients were below the age of 7yrs.
Mean Baseline PSQSRBD value and Post-operative PSQSRBD Scale values (mean of 3rd and 7th month post-operative) was found to be 0.68 + or −0.09 and 0.14 ± 0.05, respectively. On comparing both, within a confidence interval of 95%, p value was calculated as: < 0.0001, proving it significance. Figure 2: Graph comparing pre-operative and post-operative PSQSRBD scores.
Fig. 2.
Graph comparing Pre and Post-operative PSQSRBD scores
Generic Health related Quality of life values preoperative (Baseline) was tabulated to obtain a mean of 2.6 ± 0.35. Similarly mean of postoperative (3rd and 7th month) value showed a mean of 0.99 ± 0.19. On comparing the preoperative and post-operative value with a confidence interval of 95%, P value of < 0.0001 was obtained. Figure 3: Graph comparing pre-operative and post-operative Quality of life change.
Fig. 3.
Graph comparing pre and post-operative Quality of life score
One way ANOVA and independent T test was applied and each independent variables like age, gender, BMI were compared to that of mean of quality of life change and to mean of difference of PSQSRBD Values (Table 3).
Table 3.
independent variables compared to that of the quality of life change and PSQSRBD scale change
| Count | PSQSRBD Change | QOL Change | |||||
|---|---|---|---|---|---|---|---|
| Mean | SD | p | Mean | SD | p | ||
| Age category | |||||||
| 5–6yrs | 13 | .53 | .09 | 0.6 | 1.67 | .42 | 0.34 |
| 7–8yrs | 9 | .53 | .13 | 1.71 | .30 | ||
| > 9yrs | 15 | .57 | .11 | 1.51 | .35 | ||
| Sex | |||||||
| Female | 16 | .54 | .11 | 0.7 | 1.73 | .46 | 0.08 |
| Male | 21 | .55 | .10 | 1.52 | .24 | ||
| BMI category | |||||||
| < 15 kg/m2 | 15 | .54 | .12 | 1.69 | .47 | 0.3 | |
| > 15 kg/m2 | 22 | .55 | .10 | 0.7 | 1.56 | .27 | |
| Tonsil size | |||||||
| Grade 2 | 7 | .60 | .08 | 1.62 | .34 | 0.3 | |
| Grade 3 | 25 | .54 | .11 | 0.4 | 1.56 | .33 | |
| Grade 4 | 5 | .52 | .11 | 1.85 | .54 | ||
| Adenoid grade | |||||||
| Grade 3 | 27 | .54 | .11 | 1.56 | .35 | 0.1 | |
| Grade 4 | 10 | .57 | .11 | 0.4 | 1.76 | .38 | |
Discussion
It was in 1976, Guilleminault C[10], published the very first case series on paediatric OSA which came 100yrs after the 1st description of OSA in children by Hill [11] in 1889. This delay can be attributed to the vagueness associated with symptoms, diagnosis and management which still exists among clinicians when it comes to paediatric OSA.
Snoring in children is found to be lot less common than adults yet about 1–5% [2, 3] of children are affected by OSA. According to literature many studies like those by Marcus CL [6], OSAS is seen more commonly in male patients which is clearly seen in our study also.
Paediatric OSA is more prevalent in children of preschool and early school going age group because of adenotonsillar hypertrophy [2], which was clearly seen in our study as well. In a study by Brunetti et al. [2] to find out prevalence of OSA in a cohort of 1207 children of southern Italy he concluded that mean age of occurrence of OSAS in their study was 8yrs. Mean age in our study population was 8.76 ± 3.39 yrs. 35.1% of our children belonged to 5–6yrs of age and 24.3% to 7–8 yrs of age.
Adenotonsillar size was the next important parameter considered in our study. In this study, majority of our patients had grade 3 and above adenoid and tonsil grade. Adenotonsillar hypertrophy is stated as a major etiological factor for OSA in children by many studies [5, 12, 13].The normal adenoid attain their maximum size between 3 and 7 years and then regress, so did in our study highest incidence of grade 4 adenoid was noted in age 3–7 years (6) (60%) and lowest incidence > 9 years (40%). This was similar to results of study by Bercin et al. [14], who in his study stated that adenoid reach a maximum age by 3–7 years and regress.
OSA is found commonly in obese adults but in case of children with adenotonsillar hypertrophy causing OSA reduced weight gain and failure to thrive is noted [13].
Considering this aspect in our study, the mean BMI was 15.64 ± 1.97 kg/m2 with a maximum BMI of 20.28 kg/m2 and minimum value being 12.44 kg/m2.
The mean baseline preoperative PSQSRBD value was found as 0.68 + or −0.09 and mean post-operative value was found to be 0.14 + or −0.05, which when plotted within a confidence interval of 95% (CI of 95%), the value was found to be less than 0.0001 which shows the change is significant. That is post adenotonsillectomy procedure there is there is significant reduction in the symptoms of OSA in patients in our study. Effectiveness of adenotonsillectomy in 0SA patient has been evaluated using variable parameters previously in several studies in literature.
Marcus et al. [6] and Bhattacharjee et al. [15] considered normalisation of PSG values after adenotonsillectomy as parameter for assessing success of surgery in their study and was found to be 27 to 83% successful.
Whereas in other recent studies, like CHAT [16, 17] and Stewart et al. [18], they considered OSAS-18 score and quality of life score post Adenotonsillectomy surgery as a measure of success of surgery. Even in obese children with OSA, adenotonsillectomy has shown to improve quality of life and symptom outcome according to Schwimmer et al. [19].
In a meta-analysis conducted by Baldasarri et al. [20] in 2008, improvement of various parameters like PSG parameters, behaviour and quality of life was found in children post adenotonsillectomy.
CHAT trial (Randomised trial of adenotonsillectomy for children with OSA) by Marcus [6] was one of the first of its kind which highlighted the benefits of adenotonsillectomy in children with OSA, in terms of PSG parameters and quality of life measures improvement compared to watchful waiting group.
Conclusion
Obstructive Sleep Apnoea affects a significant percentage of paediatric population and is a preventable cause of future metabolic disorders and neurological problems.
Children of 5–8 yrs (pre-school and early school going) are maximally affected with paediatric OSA. Adenotonsillar hypertrophy is an important etiological factor for non syndromic paediatric OSA and not obesity.
As per literature Adenotonsillectomy is the mainstay treatment for non-syndromic paediatric Obstructive Sleep Apnoea especially in moderate to severe cases. In this study also, surgical removal of adenotonsillar hypertrophy is found to reduce the symptoms of OSA and improve behaviour and quality of life.
Funding
This study received partial support from ICMR under MD/MS/MCh/DM/MDS Thesis fund category.
Declarations
Conflict of interest
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Ethical Approval
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Consent to Participate
Informed consent was obtained from all individual participants and legal guardians included in the study.
Consent for Publication
Patients signed informed consent regarding publishing their data and photographs.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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