Piotr Kwast1, Sasza Rychlica2, Gabriela Gray2, Kamil Mierzejewski2, *Lidia Zawadzka-Głos1
The efficacy of adenotomy and adenotonsillotomy in children under three years of age – a retrospective analysis
Skuteczność zabiegów adenotomii i adenotonsillotomii u dzieci poniżej trzeciego roku życia w ocenie rodziców ? analiza retrospektywna
1Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
2Student Research Club on Laryngology in the Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Mentor of Research Club: Piotr Kwast, MD
Streszczenie
Wstęp. Przerost migdałków to jedna z najczęstszych przyczyn operacji u dzieci. Z powodu objawowego przerostu migdałków cierpią na ogół dzieci w wieku przedszkolnym. Dzieci poniżej 3. roku życia stanowią szczególną grupę pacjentów z tym schorzeniem ze względu na większe ryzyko powikłań okołooperacyjnych oraz większe prawdopodobieństwo odrostu migdałków.
Cel pracy. Celem badania była ocena skuteczności zabiegu w opinii rodziców dzieci poddanych adenotomii lub adenotonsillotomii poniżej 3. roku życia.
Materiał i metody. Przeprowadzono ankietę telefoniczną z rodzicami dzieci, które zostały poddane adenotomii lub adenotonsillotomii poniżej 3. roku życia w Klinice Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu Medycznego w latach 2015?2016. Przeanalizowano wiek, płeć i czas obserwacji pacjentów oraz objawy zgłaszane przez rodziców przed i po zabiegu.
Wyniki. Spośród 50 dzieci hospitalizowanych w Klinice, rodzice 42 pacjentów (84%) wzięli udział w ankiecie. Mediana wieku dzieci w momencie zabiegu wynosiła 2 lata i 8 miesięcy, mediana czasu obserwacji po zabiegu wynosiła 17 miesięcy. Zabieg jako nieskuteczny ocenili rodzice 2 dzieci (5%). Chrapanie występowało przed zabiegiem u 76% dzieci, bezdechy ? u 52%, a niedosłuch ? u 57%. Rodzice zgłaszali utrzymywanie się tych objawów tuż po zabiegu u odpowiednio 12%, 2% i 21% dzieci. W momencie przeprowadzania ankiety powyższe objawy występowały u odpowiednio 29%, 0% i 26% dzieci. Satysfakcja rodziców z zabiegu była większa w przypadku dzieci, u których w momencie zbierania ankiety występowały mniej nasilone objawy (współczynnik korelacji r Spearmana -0,515 przy p = 0,0005). Nie stwierdzono innych istotnych zależności pomiędzy czasem obserwacji, płcią i wiekiem dziecka w momencie operacji a nasileniem objawów przed i po zabiegu.
Wnioski. Adenotomia i adenotosillotomia u dzieci poniżej 3. roku życia są zabiegami skutecznymi w ocenie rodziców. Należy pamiętać o innych możliwych przyczynach objawów typowych dla przerostu migdałków, zwłaszcza u młodszych pacjentów. Krótka i prosta ankieta telefoniczna pozwoliła uzyskać wysoki wskaźnik odpowiedzi.
Summary
Introduction. Adenoid and tonsillar hypertrophy is one of the most common indications for surgery in children. Symptomatic adenoid and tonsillar hypertrophy mostly affects pre-school children. Children under 3 years of age constitute a distinct group of patients suffering from this disease, as they are more prone to perioperative complications, as well as to the adenoid regrowth.
Aim. The aim of the study was to assess the efficacy of surgery as seen by the parents of children under 3 years of age who had undergone adenotomy or adenotonsillotomy.
Material and methods. A telephone survey with the parents of children who had undergone adenotomy or adenotomy under 3 years of age in the Department of Pediatric Otolaryngology of the Medical University of Warsaw in the years 2015?2016 was conducted. Age, sex, time elapsed from the procedure, as well as symptoms reported by the parents before and after the procedure were analyzed.
Results. Out of 50 children hospitalized in our Department, the parents of 42 patients (84%) took part in the survey. The median age of children at the time of the surgery was 2 years and 8 months, and the median follow-up from the procedure was 17 months. The procedure was assessed as infective by the parents of 2 patients (5%). Snoring occurred in 76% of children before the procedure, apnea ? in 52%, and hearing impairment ? in 57%. The parents reported the persistence of these symptoms in 12%, 2% and 21% of the children, respectively. At the time of the survey, the above-mentioned symptoms were present in 29%, 0% and 26% of the children, respectively. The parents’ satisfaction with the procedure was greater in cases of children who had less severe symptoms at the time of the survey (Spearman’s rank correlation coefficient = -0.515, p = 0.0005). There were no other significant correlations between the time elapsed from the surgery, sex, age of the child at the time of the procedure, and symptom severity before and after the surgery.
Conclusions. Adenotomy and adenotonsillotomy are efficient as seen by the parents of children under 3 years of age. Other possible causes for symptoms typical for adenoid hypertrophy must be taken into account, especially in younger patients. A short and simple telephone survey enabled to achieve a high response rate.
Introduction
Adenoid and tonsillar hypertrophy is one of the most common indications for surgery in children. In 2016, a total of 48,000 surgical procedures on adenoids and tonsils were performed in children in Poland (1). The most frequently performed procedure was adenoid excision (60% of patients), as well as surgery on both adenoid and tonsils ? adenotonsillotomy or adenotonsillectomy (33% of patients) (1). Symptomatic adenoid and tonsillar hypertrophy mostly affects pre-school children (2). Younger children constitute a special group of patients due to the greater risk associated with general anesthesia (3, 4), as well as a higher risk of adenoid regrowth after surgery (5, 6). It is also a group that is more prone to respiratory complications in the postoperative period (7-9). Symptomatic adenoid and tonsillar hypertrophy affects the children’s quality of life and should be treated (5).
Aim
The aim of the study was to assess the efficacy of surgery as seen by the parents of children who had undergone adenotomy or adenotonsillotomy under 3 years of age.
Material and methods
Children who had undergone adenotomy or adenotomy under 3 years of age in the Department of Pediatric Otolaryngology of the Medical University of Warsaw in the years 2015?2016 were included in the study. A telephone survey with the parents of children was conducted in October 2017. The parents were asked about their perceived overall efficacy of the surgery, as well as the presence of snoring, apnea, and hearing impairment in their child before the procedure, shortly after the procedure, and at the moment of collecting the survey. The contents of the survey are shown in figure 1.
Fig. 1. The survey presented to the parents
Age and sex of the children, together with symptoms reported by the parents before and after the procedure, as well as at the moment of collecting the survey, and type of procedure were analyzed. The results were then subjected to statistical analysis.
Results
In the hospital computer system, 50 children who had met the inclusion criteria were identified and included in the study. Parents of 42 patients (84%) took part in the survey. The age of children at the time of the surgery ranged from 1.5 to 3 years (median 2 years and 8 months).
The study group included 29 boys and 13 girls. Time elapsed from the procedure at the moment of collecting the survey ranged from 6 to 28 months (median 17 months). In our study group, 20 children underwent adenotomy, and 22 ? classical adenotonsillotomy. The characteristics of the study group are summarized in table 1 and figure 2.
Tab. 1. Characteristics of the study group
| Type of procedure | |
| Adenotonsillotomy | 22 |
| Adenotomy | 20 |
| Sex | |
| Boys | 29 |
| Girls | 13 |
| Age at the time of the procedure | 18?26 months (median 32 months) |
| Follow-up | 6?28 months (median 17 months) |
Fig. 2. Age distribution in the study group
At the moment of collecting the survey, 26 parents (61%) assessed the procedure as “effective”, 15 (36%) as “partly effective”, and 2 (5%) assessed the procedure as “ineffective”.
Snoring occurred in 32 (76%) of children before the procedure, apnea ? in 22 (52%), and hearing impairment ? in 24 children (57%). The parents reported the persistence of snoring in 5 children (12%), apnea in 1 child (2%), and hearing impairment in 9 children (21%). At the time of the survey, the above-mentioned symptoms were present in 12 (29%), 0, and 11 (26%) of children, respectively. The prevalence of symptoms before and after the surgery is presented in figure 3.
Fig. 3. The prevalence of symptoms before and after the surgery
The parents of 28 children (67%) reported a complete lack of the above-mentioned symptoms one month after the procedure. There were 22 asymptomatic patients (52%) at the moment of collecting the survey.
The efficacy of the procedure perceived by the parents did not significantly correlate with the patient’s age at the time of surgery (rs = 0.3; p = 0.05) nor with the time elapsed from the procedure (rs = 0.24; p = 0.13). The efficacy was not influenced by the type of surgery. There was a moderate correlation between the perceived efficacy and the summary assessment of the severity of the symptoms at the moment of collecting the survey (rs = 0.51; p < 0.01). There was a weak correlation (R = -0.311) between the age at surgery and the severity of the symptoms at the moment of collecting the survey (rs = 0.31; p = 0.04).
Discussion
Snoring, apnea, and hearing impairment that the parents of the children have been asked about are frequent symptoms of adenoid hypertrophy in children. Both the symptoms reported by the parents, as well as their overall satisfaction from the procedure, are subjective. They were not, due to the form of the study, confirmed with laryngological assessment and objective studies. The children who experienced symptoms at the moment of collecting the survey were referred to the laryngological out-patient clinic.
In surgical treatment of adenoid hypertrophy, adenotomy is used. In case of tonsillar hypertrophy, the patient can be referred for tonsillectomy (TE), which consists of complete enucleation of the tonsils, or tonsillotomy, which consists of the reduction of their size. According to the American guidelines, the comprehensive adenotonsillectomy (ATE) is the basis of the symptomatic treatment of adenoid and tonsillar hypertrophy in children (2, 9). Adenotonsillotomy (ATT) has been gaining more and more popularity in the recent years (10). Researchers point to its comparable efficacy and lower postoperative risk, as well as faster return to normal activity of a child (10). The recommendations of the Polish Society of Otolaryngologists ? Head and Neck Surgeons indicate TE as the first choice for surgical treatment as suggest considering TT in selected children under 10 years of age (11).
In our clinical practice, TT is much more commonly performed that TE, especially in younger children. AT usually accompanies all the procedures conducted on tonsils, as adenoid hypertrophy is observed in the vast majority of the patients. All of the patients in our study group underwent AT or ATT, and none of the underwent tonsillectomy.
In the scientific literature published in English, there are papers assessing the efficacy of ATE or comparing the efficacy of ATE and ATT based on the results of polysomnography (PSG) (7, 8, 12, 13). Due to a very low availability of this examination for children in Poland, it is practically impossible to replicate such a study in our country. In 2016, 282 PSG examinations were performed in total in Poland in patients younger than 18 years of age, with 48,000 adenoid and tonsillar surgical procedures performed at the same time (1).
The second group of publications in English examines the efficacy of adenoid and tonsillar procedures as seen by the guardians of the children. There are standardized questionnaires created for this purpose. The OSA-18 questionnaire assesses the severity of the symptoms of apnea during sleep (14), the T-14 questionnaire assesses the efficacy of the TE and ATE procedures (15), and Glasgow Benefit Inventory assesses the postoperative condition of the laryngological patients (16). Unfortunately, these questionnaires are only available in English and although Polish researchers do use their translations (17), the Polish versions have never been standardized.
No lower age limit for adenoid and tonsillar surgery has ever been established, however, they are rarely performed in children younger than 3 years of age (18). In the Department of Pediatric Laryngology of the Medical University of Warsaw, patients under 3 years of age consisted about 1% of children who had undergone AT or ATT in the years 2015?2016.
Children younger than 3 years of age constitute a distinct group of patients. The American Food and Drug Administration, as well as European anesthesiologic associations, draw attention in their statements to possible adverse effects of general anesthesia in patients from this age group and recommend special caution in the qualification for surgical procedures under general anesthesia in children up to 3 years of age (3, 4). The American Laryngological Association underlines the more frequent occurrence of breathing problems in young children after adenoid and tonsillar surgery (9). Other authors emphasize that adenoid and tonsils are more likely to regrow in patients who underwent surgery at a younger age (5, 19). Sathe et al. (20), in a systematic review performed in 2017 comparing the efficacy of TT and TE in children aged from 2 to 16 years of age, indicated that the percentage of re-operations due to regrowth to be 1% in patients undergoing TE and 4% in patients undergoing TT.
Kanmaz et al. (21), studying the impact of ATE on the quality of life, showed a relatively greater improvement in younger children. In spite of the doubts associated with operating the youngest children, these procedures have been gaining much popularity in the recent years. Borgström et al. (22), describing the trends of adenoid and tonsillar procedures on Swedish children, indicated that there has been a fourfold increase in the frequency of surgery in children aged less than 3 years, and a twofold increase in the general pediatric population. AT and ATT procedures are considered safe and efficient, also for the youngest patients (23).
In our study, the relatively short telephone survey enabled us to obtain a high response rate of 84%. Other researchers using questionnaires sent to the guardians of the patients generally obtained lower response rates. Jeon et al. (24) achieved a response rate of 50% 6 months after the surgery and < 10% after a year. It must be taken into account that telephone survey is not ideal for accurate answers of the parents, who, while talking to the Department’s employee, may give inadequate answers concerning the efficacy of the procedure on purpose.
In the majority of the studies assessing the parent’s satisfaction with the procedure, > 90% of the parents are satisfied (6, 17, 25-28). In our study, the efficacy of the procedure as assessed by the parents of the youngest children is lower than the efficacy reported in other studies conducted on wider age groups. The treatment was assessed as fully effective by 60% of the parents, and the symptoms resolved after surgery in 67% of children. During the several months of observation, about half of the patients from the study population were symptomatic. Further observation of patients undergoing surgery under 3 years of age is necessary in order to assess the persistence or recurrence of symptoms in the longer term. For a wider age group of children, the mean time from the primary surgery to the symptomatic regrowth of the adenoid or tonsillar tissue ranged from 1.5 to 4 years (19, 29). It should be borne in mind that adenoid and tonsillar hypertrophy are not the only causes of the symptoms reported by the parents. A lower percentage of fully satisfied parents of children in the studied age group indicate the possibility of coexistence of additional causes of the symptoms and therefore, the need for special diligence in children under 3 years of age that are qualified for adenotomy or adenotonsillotomy. This confirms the need to treat this age group with special attention.
Conclusions
Adenotomy and adenotonsillotomy lead to the resolution of symptoms reported by the parents and are efficient as seen by the parents of children under three years of age. The satisfaction with the procedure correlates with the occurrence of symptoms at the moment of collecting the survey, but not necessarily with the degree of symptom reduction achieved with the surgery, and is independent of the time of the postoperative follow-up nor the scope of the procedure (adenotomy/adenotonsillotomy). A short and simple questionnaire made it possible to achieve a high response rate in the telephone survey. The results of our study may indicate that coexisting causes of snoring, apnea and hearing impairment occur more frequently in children that are younger than 3 years of age.
Piśmiennictwo
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