Predictors of failure of DISE-directed adenotonsillectomy in children with sleep disordered breathing

Abstract

BackgroundAdenotonsillectomy (AT) is the most commonly performed procedure for sleep disordered breathing (SDB) in pediatrics. However, 20-40% of patients will have persistent signs and symptoms of SDB after AT. Drug-induced sleep endoscopy (DISE) has the potential to individualize surgical treatments and avoid unnecessary or unsuccessful surgeries. The objective of this study was to determine the predictors of failure of DISE-directed adenoidectomy and/or tonsillectomy in otherwise healthy children with SDB.MethodsWe retrospectively reviewed a prospective database of children who presented with SDB. All patients underwent preoperative pulse oximetry (PO), followed by DISE with T ± A, The variables documented included demographics, ethnicity, co-morbidities, family history, McGill Oximetry Score (MOS) on PO, as well as findings of collapse and or obstruction on DISE and symptom resolution based on modified Pediatric Sleep Questionnaire (PSQ). The primary outcome was the independent predictors of treatment failure based on multivariate binary logistic regression.ResultsThree hundred eighty-two patients satisfied the inclusion criteria. Based on post-operative modified PSQ, SDB resolved in 259 patients (68%), whereas 123 (32%) had persistent symptoms. On bivariate analysis, neuropsychiatric diagnosis (r = 0.286, p = 0.042), history of sleepwalking or enuresis (r = 0.103, p = 0.044), MOS (r = 0.123, p = 0.033), presence of DNS (r = 0.107, p = 0.036), and presence of laryngomalacia (r = 0.122, p = 0.017) all positively correlated with treatment failure. Small tonsil size on DISE correlated with treatment failure (r = −0.180, p < 0.001). Multivariate analysis identified age greater than 7 years (OR = 1.799, [95% CI 1.040–3.139], p = 0.039), obesity (OR = 2.032, [95% CI 1.043–3.997], p = 0.040), chronic rhinitis (OR = 1.334, [95% CI 1.047–1.716], p = 0.025), deviated nasal septum (OR = 1.745, [95% CI 1.062–2.898], p = 0.031) and tonsil size (OR = 0.575, [95% CI 0.429–0.772], p < 0.01) as independent predictors of treatment failure.ConclusionsObese, asthmatic, and children older than seven years are at increased risk of treatment failure after DISE-directed AT. Several DISE findings can independently predict AT failure, including tonsil size, degree of chronic rhinitis, and the presence of a deviated nasal septum, and can be addressed at a second stage. Further research is needed into the role of DISE in surgically naïve patients with SDB, and to compare DISE-directed surgery with the current standard of care.

Relationship between Drug‐Induced Sleep Endoscopy Findings, Tonsil Size, and Polysomnographic Outcomes of Adenotonsillectomy in Children

“…However, the primary outcome in this study was a positive screen on a validated sleep questionnaire; they did not examine polysomnographic outcomes. 11…”

“…[4][5][6][7] Although DISE is most often used in cases of residual OSA after AT, 15 it is a low-risk procedure that has been shown to predict the outcome of upper airway procedures in adults 16,17 and has been used in some children for pre-AT evaluation and identification of obstruction. 8,9,11 Boudewyns et al reported a significant correlation between the awake tonsil score and the degree of tonsillar obstruction observed during DISE. However, they reported no correlation between tonsil score or DISE tonsil rating and AHI.…”

“…8,9 While a few studies have compared pre-AT DISE findings and awake tonsil scoring and generally found good correlation between these assessments, [8][9][10] there is a paucity of literature examining the relationship of either assessment with the outcome of AT. 7,11 This study had 2 objectives: first, to determine the correlation of tonsil size assessment and pre-AT DISE findings; second, to assess the relationship between polysomnography (PSG) outcomes of AT and (1) tonsil scores and (2) DISE ratings of tonsil and adenoid obstruction.…”

Pattern of Paediatric Adenoid and Tonsillar Surgery in Ekiti

“…A systemic indication of adenotonsillectomy includes when the tonsils become a focus for distant infection, such as infective endocarditis and glomerulonephritis [6] [10]. The indications for these surgical operations are numerous, International Journal of Clinical Medicine different in the center and often controversial among the otorhinolaryngologist, pediatrician and family physician [11] [12] [13].…”

Correlation between gonial angle and dynamic tongue collapse in children with snoring/sleep disordered breathing – an exploratory pilot study

“…Although prevalence estimates and the negative outcomes of pediatric SDB are well described within the literature, there is a paucity of data regarding predictive factors for failure of AT [ 13 ]. Previously identified independent risk factors of failure include age, obesity, chronic rhinitis, deviated nasal septum and tonsil size.…”