A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy

doi:10.1016/0165-5876(87)90091-7

International Journal of Pediatric Otorhinolaryngology

Volume 13, Issue 2, August 1987, Pages 149-156

https://doi.org/10.1016/0165-5876(87)90091-7 Get rights and content

Abstract

Hypertrophy of the tonsils and adenoids is the most common cause of obstructive sleep apnea in children. There is relatively little known about the occurrence of subclinical variations in the dimensions of the oropharynx which may predispose to the development of obstructive sleep apnea in children without obvious craniofacial abnormalities. Fifty-one children (3–10 years) were divided into two groups: the first group consisted of 18 patients with small tonsils and no history of snoring who underwent tonsillectomy for chronic tonsillitis. They were compared to a second group of 33 patients with large tonsils who underwent tonsillectomy and adenoidectomy for symptoms of obstructive sleep apnea. Age, height, weight, body surface area and tonsil weight were correlated to the dimensions of the oropharynx obtained by direct measurement intraoperatively including the length of the soft palate, anterior-posterior depth of the nasopharynx and the distances between the medial tonsillar surfaces, anterior tonslliar pillars and lateral pharyngeal walls at mid-tonsil level. Increased patient height, weight and surface area correlated positively to increased distance between the lateral pharyngeal walls and to the length of the soft palate in the patients with small tonsils. No such correlation existed in the patients with obstructive adenotonsillar hypertrophy. In addition, the distance between the lateral pharyngeal walls was significantly decreased in the group with large, obstructing tonsils as compared to those with small tonsils and no history of obstruction (P < 0.01). However, the patients with small tonsils and no obstruction had significantly longer soft plates (P < 0.01) and less depth to the nasopharynx (P < 0.01). As expected, tonsil weight was significantly greater in obstructed patients (P < 0.01). Diminished oropharyngeal size in addition to adenotonsillar hypertrophy may contribute to the development of obstructive sleep apnea in otherwise normal children. Previous observations that excessive soft palate length and shallow nasopharyngeal depth predispose to the development of obstructive symptoms were not confirmed by this study.

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Expression of periostin in aeroallergen-sensitized children with adenotonsillar hypertrophy
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The association between adenotonsillar hypertrophy (ATH) and allergies remains controversial. Periostin is an important player in allergic diseases. We aimed to investigate the expression of periostin in hypertrophic tonsils and adenoids in children.
We enrolled 24 children who underwent adenotonsillectomy due to sleep-disordered breathing. They were divided into atopic and control groups according to ImmunoCAP results. The presence and location of periostin in the tonsils and adenoids were determined by immunohistochemical staining. The mRNA expression and protein levels of periostin and inflammatory cytokines were measured.
Immunoreactive periostin signals were observed in the subepithelial regions and germinal centers of both tonsils and adenoids. In the subepithelial regions and germinal center, periostin signals were more prominent in both tonsils and adenoids of the atopic group than in those of the control group. Significantly, the atopic group had higher periostin mRNA expression in tonsils and adenoids than the control group. The atopic group also had higher protein level of periostin in the adenoids than the control group. Atopic children had higher TGF-β1 levels in the tonsils and adenoids than those in the controls.
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Polysomnography is considered the gold standard tool to establish the diagnosis and severity of obstructive sleep apnea (OSA) syndrome in children; however, it cannot provide information regarding the mechanism or location of upper airway obstruction during sleep. The present chapter will focus on the role of imaging modalities in evaluating childhood OSA and how they may advance our understanding of the anatomical and functional aspects of the disorder. Although routine imaging for children with OSA is not required, advanced imaging techniques are an important component of the evaluation for some children, including those with complex medical comorbidities, craniofacial anomalies, and persistent disease following first-line therapy. In this chapter, we emphasize studies using magnetic resonance imaging, since this technique is noninvasive and provides the most quantitative and reliable data without ionizing radiation. Lateral neck radiography, sleep fluoroscopy, computed tomography, and optical coherence tomography are also discussed.
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Pediatric obstructive sleep apnea (OSA) is a common and consequential disorder in children; experts have published multiple clinical practice guidelines to assist providers with management. Clinical practice guidelines provide evidence-based recommendations for best practices. Experts examine the quality of the evidence available to determine the relative benefit versus harm of various tests and treatment options. Ultimately, guidelines are intended to supplement rather than replace clinical judgment. This chapter will summarize current guidelines for diagnosing and managing pediatric OSA. We will discuss guidelines for screening, diagnosis, treatment (both medical and surgical), perioperative management, and follow-up care.
Adenotonsillectomy
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Tonsillectomy with or without adenoidectomy (referred to herein as adenotonsillectomy (AT) unless otherwise specified) is the mainstay of surgical treatment for children with sleep-disordered breathing and obstructive sleep apnea. In this chapter, we review AT. A brief historical and anatomical overview is followed by a review of technical aspects and consideration of those complications which are common and concerning.
Evaluation of the relationship between the stop-bang score with oxygen reserve index and difficult airway: a prospective observational study
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Patients diagnosed with Obstructive Sleep Apnea (OSA) syndrome have a tendency towards hypoventilation, hypoxia, and hypercarbia in the perioperative period. This study hypothesized that the Oxygen Reserve Index (ORi) could predict possible hypoxia and determine difficult airways in patients at risk for OSA, as determined by the STOP-Bang questionnaire.
This prospective study included adult patients undergoing elective surgery under general anesthesia with endotracheal intubation, divided into two groups: low risk (0–2 points) and high risk (3–8 points) based on their STOP-Bang questionnaire results. The primary outcome measure was the highest ORi value reached during preoxygenation and the time to reach this value. Data were recorded at four time points: before preoxygenation (T1), end of preoxygenation (T2), end of mask ventilation (T3), and end of intubation (T4), as well as partial oxygen pressure values in T1, T2, and T4. The secondary outcome measures were the grading scale for mask ventilation, Cormack-Lehane score, tonsil dimensions, use of a stylet, and application of the burp maneuver during intubation.
In the high-risk group, preoperative peripheral oxygen saturation values, the highest ORi value reached in preoxygenation, and ORi values at T3 and T4 times were lower, and the time to reach the highest ORi value was longer (p < 0.05).
Using ORi in patients with OSA may be useful in evaluating oxygenation, and since difficult airway is more common, ORi monitoring will better manage possible hypoxic conditions.
Measurements of craniofacial morphology using photogrammetry in children with sleep-disordered breathing
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Citation Excerpt :
Furthermore, children who did not achieve standard photogrammetry position were excluded. Routine ENT examinations were performed on each child, including assessment of tonsillar size according to Brodsky grading scale (0–4+) [13], nasal anterior rhinoscopy, and Friedman tongue position (FTP) [14]. Tonsillar size ≥3+ is defined as tonsillar hypertrophy [15].
To assess the craniofacial morphology in children with sleep-disordered breathing (SDB) using nonradiation and readily accessible photogrammetry technique.
Included children aged 3–18 years with SDB-related symptoms from April 2019 to February 2020 in a tertiary center. All participants underwent craniofacial photogrammetry and overnight polysomnography (PSG). Participants were stratified into 2 groups (obstructive sleep apnea [OSA] group: apnea-hypopnea index [AHI] ≥ 1 and non-OSA group: AHI <1). Craniofacial photogrammetry was performed to derive variables of craniofacial features in standardized frontal and profile views. The 2 groups were propensity score matched based on age, sex, and body mass index (BMI) percentiles. Associations between craniofacial feature variables and OSA (AHI ≥1) likelihood were examined using logistic regression test. intraclass correlation coefficient (ICC) was used to evaluate the intrarater and interrater reliability.
In total, 58 children were enrolled for the analysis after matching. All 3 variables representing the mandibular plane angle in the profile view were increased in the OSA group (mego-tn: 34.85 ± 5.99 vs 31.65 ± 5.96°, odds ratio [OR]: 1.10, 95% CI:1.02 to 1.18, P = .01; tn-gogn: 28.65 ± 6.38 vs 25.91 ± 5.38°, OR: 1.08, 95% CI:1.02 to 1.15, P = .012; and gome-tsup: 26.71 ± 6.13 vs 22.20 ± 5.89°, OR: 1.13, 95% CI:1.04 to 1.23, P = .003).
Craniofacial photogrammetry revealed increased mandibular inclination in children with OSA. A steep mandibular plane with craniofacial photogrammetry is considered a potential predictor of pediatric OSA. Further investigation with a large sample size is required to clarify the validity of photogrammetry in evaluating pediatric OSA.

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^☆: Presented at the Annual Meeting of the Society for Ear, Nose and Throat Advances in Children (SENTAC), Philadelphia, PA, U.S.A., December 4–7, 1986.

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PaperA comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy☆

Abstract

J. Pediatr.

Am. J. Orthod.

Ped. Clin. N. Am.

Am. J. Orthodon.

Pharyngeal size in snorers, non-snorers and patients with obstructive sleep apnea

New Engl. J. Med.

Radiologic evaluation of adenoids and tonsils in children with obstructive sleep apnea: plain films and fluoroscopy

Pediatr. Radiol.

Radiographic evaluation of adenoid size in children: adenoid-nasopharyngeal ratio

Am. J. Radiol.

A review of 50 children with obstructive sleep apnea syndrome

Lung

Computerized tomography in obstructive sleep apnea

Am. Rev. Respirat. Dis.

Flow volume curves and sleep disordered breathing: therapeutic implications

Thorax

Paper
A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy☆