Most Pediatric ENTs Remove Tonsils for Apnea without a Sleep Study

Newswise — Adenotonsillar hypertrophy, more commonly known as enlarged tonsils and adenoids, is the main cause of sleep-disordered breathing (SDB) in children. There is increasing evidence that adenotonsillectomy is effective at improving sleep, daytime behavior and quality-of-life. Additionally, the last two decades has seen an increasing recognition of an association between sleep-disordered breathing and daytime behavioral problems in children. Adenotonsillectomy has traditionally been performed for recurrent Streptococcal tonsillitis and its consequences. However, in recent times, the prevalence of SDB has made that condition the primary indication for surgical excision of the tonsils and adenoids in children. Several studies have also shown that a clinical diagnosis correlates poorly with the presence or severity of SDB as confirmed by polysomnography (PSG) or sleep study.

A new study examines the management of children with SDB by members of the American Society of Pediatric Otolaryngologists (ASPO). The authors of "Sleep-Disordered Breathing in Children: Survey of Current Practice" are Ron B. Mitchell MD, Associate Professor, Departments of Otolaryngology and Pediatrics, Virginia Commonwealth University; Kevin D. Pereira MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, The University of Texas Medical School at Houston; and Norman R. Friedman MD, Assistant Professor, Department of Otolaryngology, University of Colorado Health Sciences Center. Their findings will be presented at The Twentieth Annual Meeting of the American Society of Pediatric Otolaryngology (ASPO) http://www.aspo.us/ being held May 27-30, 2005, at the J.W. Marriott Las Vegas Resort in Las Vegas, NV.

Methodology: In March 2004, 245 questionnaires were sent electronically to members of ASPO. A second survey was sent 30 days later to non-responders. The survey was anonymous but coded to identify non-responders and ensure elimination of multiple responses. An 18-question survey was designed that asked about the pre-operative and post-operative management of children with SDB. The investigators designed the survey after a thorough review of the literature. The survey data were reported as a percentage of total response to each question. Variables were cross-tabulated and a Pearson Chi-Square was used for statistical analysis (SPSS version 12). The level of significance was set at P < 0.05.

Results: Of the 245 questionnaires, 107 (44 percent) were considered for analysis. Twenty-six percent reported being in practice for more than 20 years, 45 percent between 10 and 20 years, 27 percent between 5 and 10 years and 2 percent less than 5 years. Seventy-two percent completed a pediatric otolaryngology fellowship and 84 percent practiced in a children's hospital. The majority of pediatric otolaryngologists (89 percent) reported that 10-50 percent of their practice involved the management of children with a sleep disturbance. Eighty-three percent of respondents had access to a sleep laboratory and for 67 percent of respondents this was a dedicated pediatric facility. For 43 percent of respondents a pediatric sleep study involved a wait of more than 6 weeks.

The present study shows that the overwhelming majority of pediatric otolaryngologists rely on a clinical diagnosis of SDB rather than PSG to schedule surgery. Parents often report snoring, restless sleep and breath-holding episodes in their children. Daytime symptoms include excessive somnolence, hyperactivity and aggressive behavior. When these signs and symptoms are present and examination confirms adenotonsillar hypertrophy, a majority of respondents would proceed with surgical therapy despite a normal PSG.

Conclusions: There is ongoing debate as to the role of PSG in the pre-operative management of children with SDB. The American Academy of Pediatrics in a clinical practice guideline on the diagnosis and management of childhood SDB recommends that children be routinely screened for snoring. In children who are symptomatic, PSG is recommended as the diagnostic test of choice. An official statement of the American Thoracic Society provides similar recommendations.

The present study highlights some of the difficulties in following these recommendations. In this survey, 17 percent of respondents did not have access to a sleep-laboratory and 40 percent did not have access to a dedicated pediatric facility. In addition, over 50 percent waited for six-weeks or longer to obtain PSG. Clearly, routine pre-operative PSG in all children with suspected SDB is currently not feasible.

The strength of this study is that it included the practice patterns of over 100 pediatric otolaryngologists from a broad geographic base and drawn from a national professional society. The anonymity of the survey ensured that participants could freely answer the questions without medico-legal concerns. Several limitations need to be recognized. Firstly, the response rate of 44 percent was low but in keeping with previous surveys. There was no way of surveying non-responders and comparing their answers to responders. The study was also directed at ASPO members who may not represent the practice patterns of non-ASPO otolaryngologists.

Despite these limitations, the present study does characterize the management of children with SDB by pediatric otolaryngologists. The majority of children with SDB undergo adenotonsillectomy without pre-operative PSG; they are rarely observed overnight after surgery or undergo post-operative PSG. The current practice of pediatric otolaryngologists differs from the recommendations of the American Academy of Pediatrics and the American Thoracic Society. To achieve compliance, objective criteria for the use to PSG to justify adenotonsillectomy in children with SDB are required. Research to develop these criteria would establish age- and gender-specific criteria based on statistical analysis of the following data: PSG findings; clinical findings; parental reports; patient demographics; and comorbidities. Child behavior and quality-of-life may also play a role in the evaluation of therapy for SDB. A long-term research project to develop objective criteria for adenotonsillectomy is currently in progress based on a large sample of children with SDB.