Association of Preoperative, Subjective Pediatric Tonsil Size With Tonsillectomy Outcomes

Abstract

IMPORTANCE Tonsil size assessment on physical examination is often used as a key component of clinical decision-making, specifically in estimating the success or failure of adenotonsillectomy surgery. The accuracy of this approach is not specifically known.OBJECTIVE To systematically review the biomedical literature for data comparing subjective preoperative tonsil (and adenoid) size (0-to >4-point scale) with adenotonsillectomy outcomes using polysomnography and/or quality of life outcomes. EVIDENCE REVIEW A PubMed and Embase search was conducted from June 1, 2018, through November 1, 2018, to identify articles comparing preoperative subjective tonsil and adenoid size with surgical outcomes. Key search terms included adenotonsillectomy, tonsil size, Brodsky scale, apnea-hypopnea index, OSA-18, polysomnography, and quality of life, with limits of 0 to 18 years of age. Inclusion criteria included articles on pediatric patients only, articles on patients who underwent tonsillectomy or adenotonsillectomy, and articles that included presurgical and postsurgical data. Exclusion criteria included patients who received surgery beyond adenotonsillectomy and studies that did not compare tonsil and adenoid size grades with surgical outcomes. FINDINGS A total of 27 studies were included in the final data set. The mean sample size was 79.7 (range, 17-250), and the mean age was 6.3 years (range, 4.2-12.8 years). Case series was the predominant study design (20 studies). Fourteen studies specifically excluded obesity and craniofacial syndromes, whereas 2 studies addressed patients with trisomy 21 only, and 5 studies focused on patients with obesity. Outcome measures included polysomnography (19 studies), Obstructive Sleep Apnea 18 survey (4 studies), Obstructive Sleep Apnea 6 (1 study), oxygen desaturation index (1 study), and overnight pulse oximetry (1 study). Ten studies conducted postoperative evaluations within 90 days of the intervention, and 17 studies had greater than 90-day follow-up. A total of 22 of the 27 studies (81.5%) concluded that there was no association between tonsil and adenoid size and surgical outcome, whereas 5 studies (18.5%) concluded that there was an association. Studies that found no association had a higher mean quality score than those that found an association (15.6 vs 14.5; difference in means, 1.13; 95% CI, 0.07-2.19). CONCLUSIONS AND RELEVANCEMost published clinical evidence suggests that subjective tonsil and adenoid size is not reliably associated with adenotonsillectomy success or failure because success rates are typically high regardless of tonsil size. Physicians should understand the potential limitations of using tonsil size alone as the key component of clinical decision-making for adenotonsillectomy.

Effect of adenoids and tonsil tissue on pediatric obstructive sleep apnea severity determined by computational fluid dynamics

“…We were able to use CFD to analyze the pharyngeal airway and determine an association between pharyngeal airway pressure, pharyngeal airway size, and OSA severity. Several epidemiologic studies [6][7][8] examined AT grade and its relationship to OSA. However, these studies [6][7][8] only examined the association statistically without discussing mechanism.…”

“…Several epidemiologic studies [6][7][8] examined AT grade and its relationship to OSA. However, these studies [6][7][8] only examined the association statistically without discussing mechanism. Therefore, a consensus was not reached concerning the association between AT grade and OSA severity until now.…”

“…Therefore, it is not clear to what extent AT enlargement causes OSA. Bally et al 8 reported that these evaluation methods not only require further evaluation themselves, but they also must ascertain the effect that enlarged adenoids and tonsils have on the airway.…”

Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond

“…Other measures for determining OSA in lieu of PSG have been examined. These surrogate measures of OSA include tonsil size [13,24,25] clinical assessment, questionnaires [24,26], sleep videos [23], and overnight oximetry [14,24,27], with notable variables and often contested capacity to accurately identify children with OSA. As such, there is currently little consensus on the best way to define pediatric OSA that is widely applicable, accessible, successful, and cost effective when considering surgical management to treat the disease.…”

Der KINDL-Fragebogen zur Erfassung der allgemeinen Lebensqualität bei adenotonsillärer Hyperplasie

“…Da jedoch insbesondere die Tonsillotomie einen relevanten Einfluss auf die Lebensqualität der Kinder in unserem Kollektiv zu haben scheint, sollte bei zusätzlicher Hyperplasie der Gaumenmandeln die Indikation zur Tonsillotomie im Rahmen einer Adenotomie unserer Meinung nach durchaus großzügiger gestellt werden. In der Literatur zeigt sich zwar keine klare Korrelation zwischen der "reinen" Größe der Gaumen-und Rachenmandeln und dem Schweregrad einer kindlichen Schlafapnoe sowie dem Erfolg der Operationen [29], jedoch wurden hier erneut Adenotonsillektomien ausgewertet. Im Vordergrund sollte daher aus unserer Sicht die Erfassung des OSAS-Risikos durch gezielte Anamnese und die erlebte Belastung durch die Symptome stehen.…”