Kinga Siewiorek1, Olga Siewiorek1, Piotr Kwast1, 2, *Lidia Zawadzka-Głos2
Adenoidectomy and adenotonsillotomy in children less than 2 years of age – a retrospective analysis
Adenotomia i adenotonsillotomia u dzieci poniżej 2. roku życia – analiza retrospektywna
1Student Research Club on Laryngology in the Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Mentor of Research Club: Piotr Kwast, MD
2Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Funkcją migdałków podniebiennych i gardłowego jest udział w mechanizmach obronnych. Ciągła stymulacja antygenami powoduje przerost migdałków, który, w określonych przypadkach, może stanowić wskazanie do ich usunięcia.
Cel pracy. Celem pracy była analiza grupy dzieci poniżej 2. roku życia poddanych adenotomii lub adenotonsillotomii pod względem: zgłaszanych objawów, rodzaju wykonanego zabiegu, chorób współistniejących oraz niepożądanych objawów w pierwszej dobie po zabiegu.
Materiał i metody. Do badania włączono dzieci poniżej 2. roku życia, hospitalizowane w latach 2009-2016 w Klinince Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu medycznego z powodu przerostu migdałków, u których wykonano zabieg operacyjny. Spośród wszystkich 5833 pacjentów z przerostem migdałka gardłowego i/lub podniebiennych, 60 (29 dziewczynek, 31 chłopców) spełniało kryteria badania. Oceniono zgłaszane objawy, choroby współistniejące, rodzaj zabiegu i niepożądane objawy w pierwszej dobie po operacji w poszczególnych grupach wiekowych.
Wyniki. U 38 pacjentów wykonano adenotomię, a u 22 adenotonsillotomię. U 26 dzieci współwystępowało wysiękowe zapalenie ucha środkowego leczone dodatkowo tympanocentezą lub drenażem wentylacyjnym. Pod względem zgłaszanych objawów oraz rodzaju wykonanego zabiegu nie odnotowano istotnych statystycznie różnic w grupach wiekowych. U trojga dzieci z chorobami towarzyszącymi wystąpiły niepożądane objawy w pierwszej dobie po zabiegu: spadki saturacji oraz gorączka.
Wnioski. Adenotomia i adenotonsillotomia z współistniejącą tympanocentezą lub tympanocentezą z drenażem jest względnie bezpieczna i skuteczna u dzieci poniżej 2. roku życia. Nie wykazano ewidentnej zależności między wiekiem dziecka a częstością wykonywania adenotomii w stosunku do adenotonsillotomii. Rodzice powinni być poinformowani o możliwości odrastania migdałków po niecałkowitym ich usunięciu.
Summary
Introduction. The function of the palatine and adenoid tonsils is to provide defence against respiratory and digestive pathogens. Continuous antigenic stimulation may lead to tonsillar hypertrophy, which can be an indication for their removal.
Aim. The purpose of this study was to analyse the symptoms, comorbidities, type of procedure and adverse effects after surgery in children less than 2 years of age who underwent adenoidectomy or adenotonsillotomy.
Material and methods. Children less than 2 years of age hospitalized in the years 2009-2016 in the Department of Pediatric Otolaryngology of the Medical University of Warsaw were included in the study. Among 5833 patients with tonsillar hypertrophy, 60 patients (29 girls, 31 boys) met the inclusion criteria. Reported symptoms, comorbidities, type of procedure, and adverse symptoms during the post-operative observation period were analysed in age subgroups.
Results. Adenoidectomy was performed in 38 cases, and adenotonsillotomy – in 22 cases. 26 children had concomitant otitis media with effusion treated with myringotomy with or without tympanostomy tube insertion. In regard to the symptoms and type of the procedure, the level of statistical significance was not reached. Drops in blood oxygen saturation and fever were observed postoperatively in three children with comorbid conditions.
Conclusions. Adenoidectomy and adenotonsillotomy with myringotomy with or without tympanostomy tube insertion are relatively safe and efficient procedures in children under 2 years of age. No evident correlation between the age of the child and the frequency of performing adenoidectomy in relation to adenotonsillotomy has been noted. Parents should be informed about the risk of regrowth and the possible need for a future reoperation.
Introduction
Tonsils are a part of immunological system responsible for shaping of the defence mechanisms of the organism, particularly in newborns, after their first contact with environmental antigens (1). Increased stimulation with pathogens, especially during upper respiratory tract infections, may result in an increase of the size of the palatine and adenoid tonsils, which, in turn, may influence the development of the child (1). In order to avoid serious consequences of tonsillar hypertrophy, the indications for their removal should be considered.
Aim
The purpose of this study was to analyse the symptoms, comorbidities, type of the procedure and adverse effects after surgery in children less than 2 years of age who underwent adenoidectomy or adenotonsillotomy.
Material and methods
Children less than 2 years of age, operated due to tonsillar hypertrophy in the Pediatric Otolaryngology Department of the Medical University of Warsaw in the years 2009-2016 were included in the study. The patients were divided into two subgroups: from 6 to ≤ 18 months of age, and from 18 to ≤ 24 months of age.
The frequency of reported symptoms, the type of procedure, comorbidities and adverse symptoms during the post-operative observation period were compared between the age subgroups.
Two-tailed Fisher’s exact test has been used to assess statistical significance.
Results
Among 5833 patients with tonsillar and/or adenoid hypertrophy hospitalized in the Department of Pediatric Otolaryngology of the Medical University of Warsaw, 60 patients (29 girls, 31 boys) met the inclusion criteria. The number of children from 6 to ≤ 18 months of age, and from 18 to ≤ 24 months of age was 21 and 39, respectively. 38 patients underwent adenoidectomy, and 22 – adenotonsillotomy. Adenotonsillotomy was more frequently performed in older children than in younger ones, however, the difference was at the limit of statistical significance (tab. 1).
Tab. 1. Adenoid hypertrophy. Type of the procedure in the age groups
| Type of the procedure | Age group | p |
| from 6 to ≤ 18 MOA | from 18 to ≤ 24 MOA |
| N | % | N | % |
| Adenoidectomy | 17 | 80.95 | 21 | 53.85 | 0.05 |
| Adenotonsillotomy | 4 | 19.05 | 18 | 46.15 | 0.05 |
The symptoms most frequently reported by parents included: nasal obstruction (N = 50), recurrent upper respiratory tract infections (N = 46), snoring (N = 43), hearing impairment (N = 26), apnea (N = 20), recurrent otitis media (N = 8), and cough (N = 2) (fig. 1). No statistically significant differences between the age subgroups were found.
Fig. 1. Symptoms declared in age subgroups
Five children suffered from comorbid conditions: Down syndrome, Pierre Robin syndrome, psychomotor retardation, and asthma. Adverse symptoms during the post-operative observation period occurred only in the group of patients with comorbidities, and included hypoxemia (N = 2) and fever (N = 1).
Twenty-six children (43.33%) were diagnosed with otitis media with effusion. Myringotomy was performed in these patients, accompanied by tympanostomy tube insertion into the tympanic membrane in 7 cases. No statistically significant differences between age subgroups were observed in the frequency of otitis media with effusion (tab. 2).
Tab. 2. Otitis media with effusion. Type of the procedure in the age groups
| Type of the procedure | Age group | p |
| from 6 to ≤ 18 MOA | from 6 to ≤ 18 MOA |
| N | % | N | % |
| Myringostomy without tube | 6 | 28.57 | 13 | 33.33 | 0.78 |
| Myringostomy with tube | 1 | 4.76 | 6 | 15.38 | 0.40 |
Discussion
The anatomy and function of tonsils change with age. After the birth, the so-called germinal centers in tonsils take part in shaping of the defense mechanisms of the body. The mechanisms develop in the early years of life, but an increase in the rate of proliferation in the germinal center, resulting in an increase in the weight and size of tonsils, occurs at a later stage (2). This results in a change in the profile of produced antibodies and lymphocytes and in the hypertrophy of the lymphatic tissue of the pharynx, particularly in toddlers and young children (3, 4). In case of a symptomatic tonsillar hypertrophy, treatment is recommended, including surgical treatment (5).
The surgical treatment consists of performing adenotomy (partial resection of the adenoid tonsil) and tonsillotomy (partial resection of the palatine tonsils) in general anesthesia (5).
Tonsillectomy, i.e. the removal of the entire tonsils, is not routinely performed in the tonsil hypertrophy. According to the guidelines of the Polish Society of the Otolaryngologists and Head and Neck Surgeons (5), tonsillectomy is recommended in cases of chronic hypertrophic tonsillitis caused by focal infections or recurrent upper respiratory tract infections with elevated inflammatory markers and/or positive bacterial swabs. This procedure should also be considered in children over 10 years of age with apneas or developmental disorders, and tosillotomy is recommended in younger patients. The guidelines do not cover the management of the adenoid hypertrophy.
In case of otitis media, adenotomy with myringotomy is recommended (5, 6). There is evidence that this method reduces effusion lasting more than 3 months (6).
Issues related to the qualification to adenotomy and adenotonsillotomy are not precisely addressed in the guidelines. In clinical practice, thorough interview and physical examination are always performed, fiberoscopy or imaging studies are also done. In Western countries, polysomnographic examination (PSG) is considered of great importance to confirm the obstructive sleep apnea, as well as for the objective assessment of the effectiveness of the surgery (7). In Poland, the availability of polysomnography is limited, which makes it impossible to use this method routinely to confirm sleep disturbances during sleep in patients with adenoid and tonsil hypertrophy (8).
In our clinical practice, the qualification for adenotomy or adenotonsillotomy is based on the symptoms of impaired nasal patency, mouth breathing, snoring, recurrent upper respiratory tract infections, acute otitis media, hearing impairment, as well as on the signs in the physical examination: size of the tonsils, nasal patency, construction and movability of the soft palate, dental occlusion defects, presence of exudate in the tympanic cavity, and results of lateral nasopharynx x-ray or fiberoscopy of nasopharynx. Patients with suspected otitis media have tympanometry in order to confirm the diagnosis. Some patients, prior to the qualification or while awaiting surgery, receive conservative treatment in the form of nasal glucocorticoids or antihistamines in case of a suspected concomitant allergy.
An additional aspect that should be taken into account when qualifying for the surgery is the risk of general anesthesia. The issue of the effects of general anesthesia on the further mental development of young children has been raised more and more frequently. The American Food and Drug Administration (FDA) issued a statement in 2016 that recommends limiting general anesthesia in children under 3 years of age (9). A single, short general anesthesia should not have a negative impact on the development of the child, but the decision about the necessity of the anesthesia should be made taking into account expected benefits of the procedure (9). Children with adenoid hypertrophy with concomitant nasal obstruction or exudative otitis media and hearing impairment will definitely benefit from the surgery, also in the context of the future normal development. Each case of eligibility for surgery and anesthesia should be considered individually in terms of the balance of potential benefits and risks (9).
Most difficulties are related to the qualification for the procedure in children under the age of 2 (10). In our Department, this age group was represented by 60 children over an 8-year period, which accounted for 1.03% of all patients with tonsillar hypertrophy. Due to the small percentage of patients in this age subgroup, thorough research on the indications, safety and efficacy of the procedures in this age group is scarce. In the youngest children, Polish recommendations allow tonsillotomy only in exceptional situations. The American guidelines, on the other hand, only address the issue of tonsillectomy, and not tonsillotomy, in this age group (11). It is worthwhile to distinguish the population of patients under 2 years of age due to the differences in the functioning of the immune system, which is not fully developed in the youngest patients (12).
For many years, adenoidectomy had remained the most common surgical option for patients with adenoid hypertrophy (13). Tonsillotomy, although it had been first described in the 19th century, only began to be perceived as an alternative for adenoidectomy in the early 1990s (13). There are more and more reports of a comparable efficacy of both techiniques in the discussed group of patients in terms of the quality of life, effects on the symptoms of sleep apnea, and PSG results (14, 15).
Tonsillotomy is a safer procedure, with a lower rate of complications (such as perioperative bleeding, pain, and dehydration). It enables a faster return to a normal activity level and diet and it involves the use of a smaller amount of analgesics (13, 16).
Prior to tonsillotomy, the patient and parents should be informed of the possibility of the recurrence of the symptoms, such as tonsillitis and recurrent pharyngitis, resulting in tonsillar hypertrophy and the need for reintervention, which happens in 0-6% of children (14). In a large retrospective study from 2015, a significant correlation between a younger age and the need for reoperation was shown (16). In the 5-year observation period, the risk of reoperation based on the age of the child at the time of the first operation was ca. 30% for two-year old children, and above 50% for children aged one year (17). In children undergoing tonsillectomy, the percentage of reoperations was 5 and 10%, respectively (17).
In our study, undesirable postoperative symptoms were only observed in patients with comorbidities. Two cases of saturation drop to 70% and one case of fever were observed. The results are comparable to the results of an American study from 2013 concerning infants undergoing tonsillar surgery, in which a more favorable outcome was observed in healthy patients when compared with patients with comorbidities (18).
When assessing the drawbacks and the benefits of tonsillotomy when compared with tonsillectomy, the authors, like other researchers (19), suggest that one should keep in mind that the younger the child, the more important the post-operative course is, at the expense of an increased probability of recurrence. Tonsillectomy is recommended for older patients, with recurrent anginas, focal infections, peritonsillar abscesses and tumors – which is also compliant with current trends in the literature (5, 20).
Conclusions
Nasal obstruction and recurrent upper respiratory tract infections are dominant signs of tonsillar hipertrophy in children under 2 years of age. Hearing impairment and apnea observed by the parents affect half of the children in this age group. Comorbidities increase the risk of undesirable symptoms in the postoperative period. Adenoidectomy and adenotonsillotomy are rarely performed in children under 2 years of age. Adenoidectomy is performed more often than adenotonsillotomy. The difference in the frequency of the procedures in the two age subgroups was at the limit of the statistical significance, which may be due to the small sample in our study.
Due to the different functioning of the immune system in this age group, precise guidelines for the diagnostic and therapeutic procedures are needed. Partial removal of the tonsils accompanied by myringotomy and tympanostomy tube insertion in children with symptomatic adenoid hypertrophy is relatively safe and efficient, which is supported by our research and the literature. However, in children this young the decision on surgery under general anesthesia should always be made individually after considering the potential benefits and risks of the procedure. Moreover, it is worth noting that the tonsils can regenerate after partial removal, of which the parents should be informed in advance.
Piśmiennictwo
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