Cardiac and pulmonary failure secondary to adenotonsillar hypertrophy

Abstract

For over 15 years, upper respiratory tract obstruction due to adenotonsillar hypertrophy has been known to cause hypoxia, hypercapnia, increased pulmonary vascular resistance and thereby cor pulmonale and congestive heart failure. This is now an uncommon but not rare entity and three recent cases prompted this report. The typical patient is dyspneic with retractions, cyanosis, occasional periods of apnea and somnolence. Edema and hepatomegaly and at times splenomegaly are common. X-rays show cardiomegaly, which on electrocardiogram is found to involved mainly the right ventricle. The strict definition of cor pulmonale is right ventricular hypertrophy secondary to lung disease or abnormal pulmonary function, a definition that may logically be stretched to include abnormal respiratory function secondary to upper airway pathology. The mechanisms by which this occurs are generally agreed upon. Hypoxia has been demonstrated to cause pulmonary vasoconstriction. Acidosis and hypercapnia are thought by some to have the same effect. Pressure across the pulmonary vascular bed is also increased, as predicted by Poiseuille's law, by the high rate of blood flow required to maintain tissue oxygenation with poorly oxygenated blood. Conditions producing hypoxia of hypercapnia or both lead to hypertrophy and eventually to dilatation of the right ventricle. Three cases of children who underwent cardiac catheterization while suffering from cor pulmonale due to adenotonsillar hypertrophy are reported. Right ventricular pressure averaged 44/5, PAO2 72, pH 7.32, and PACO2 52. All were clinically improved following adenotonsillectomy. Cardiac catheterization was repeated in one case, with right ventricular pressure dropping from 44/5 to 21/2, pulmonary vascular resistance from eight units to three, and PACO2 from 62 to 44.

Sleep Apnea and Cardiovascular Disease

“…Complete reversibility of pulmonary hypertension was shown in 1 case after adenotonsillectomy. 412 A second report on 2 children with Down's syndrome and 1 child with Pierre Robin sequence showed evidence of pulmonary hypertension that partially decreased with oxygen supplementation. 413 …”

“…408 Direct measurements of pulmonary artery pressure by cardiac catheterization are limited to 2 case reports. 412,413 Pulmonary hypertension was diagnosed by cardiac catheterization in 3 children with symptoms of OSA, adenotonsillar hypertrophy, and cardiac failure. Complete reversibility of pulmonary hypertension was shown in 1 case after adenotonsillectomy.…”

Exposure to Mild Hypoxia Associated with Oral Breathing Affects The NK Cell Ratio in The Spleen

“…Previously, it has been reported that an upper respiratory tract obstruction associated with adenoid hypertrophy led to severe hypoxia including dyspnea and cyanosis; however, this is a rare case (11). Mbam et al reported that when the degree of percutaneous arterial oxygen saturation(SPO 2 )at night was measured using a pulse oximeter, mouth breathing children who were clinically diagnosed with tonsil hypertrophy had a decrased SPO 2 compared to normal children (12).…”

Echocardiographic abnormalities in children with obstructive breathing disorders during sleep

“…Os sintomas referidos mais freqüentes são: roncos, pausas respiratórias, dificuldade para respirar, sono agitado e sudorese noturna 2,6 . A SAHOS pode ter conseqüên-cias clínicas graves, como cor pulmonale [7][8][9] , além de impacto negativo na qualidade de vida da criança, como atraso no crescimento pôndero-estatural, alterações do esqueleto facial e torácico 10 , enurese noturna e distúrbios do comportamento, do aprendizado e de outras funções cognitivas 11 .…”