Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children
ABSTRACT This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders.
There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology--Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.
The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.
- SourceAvailable from: Prasad John Thottam
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- "Polysomnography Polysomnography was conducted within an overnight sleep laboratory at the Children's Hospital of Pittsburgh. As per AAO-HNS clinical practice guidelines on polysomnography for sleep-disordered breathing prior to tonsillectomy in children, the physiologic parameters measured included gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm  "
ABSTRACT: To analyze the outcomes of severe obstructive sleep apnea (OSA) in pediatric patients with Trisomy 21 compared with non-syndromic patients. A retrospective chart review was performed for patients with a diagnosis of severe obstructive sleep apnea, (defined as, Apnea-Hypopnea index (AHI) of ≥10) in a tertiary children's hospital. Data were analyzed for subjective and objective outcomes along with perioperative care and health care utilization. Patients with Trisomy 21 were compared with non-syndromic patients. A total of 230 patients with severe OSA were included in the study. Eighteen of these patients had Trisomy 21. Adenotonsillectomy was the most common surgical intervention in both groups. There was no statistical difference in the preoperative AHI between groups. Post treatment AHI in the Trisomy 21 group changed from an average of 26.6 to an average of 11.6 as compared with 24.5 to 3.6 in the non-syndromic group. The average perioperative hospital stay was 3.8 days in Trisomy 21 group compared to 1.7 days for the non-syndromic group (p<0.001, Mann-Whitney U test). Complete resolution was seen in 35% of the Trisomy 21 group versus 75% in the non-syndromic group. A majority of Trisomy 21 patients with severe OSA had residual symptoms following surgical intervention. There is also an increased risk of post-operative airway intervention and increased length of hospital stay in these patients. Copyright © 2015. Published by Elsevier Ireland Ltd.International journal of pediatric otorhinolaryngology 04/2015; 79(7). DOI:10.1016/j.ijporl.2015.04.015 · 1.19 Impact Factor
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- "Patients less than 3 years of age were excluded from the study in keeping with current safety guidelines that recommend post-operative admission for these patients . In addition, we excluded 13 patients with severe comorbidities (Figure 1): Cardiovascular disease (1), Trisomy 21 (3), extreme prematurity with BPD (4), atypical seizure disorder (1), neuromuscular disease (1), severe asthma requiring past ICU admissions (1), craniofacial abnormality (Goldenhar syndrome) (1), and URTI at time of surgery (1). "
ABSTRACT: Background Children with sleep-disordered breathing (SDB) are at risk of developing post-operative respiratory complications following adenotonsillectomy (T&A). Our goal was to describe and quantify these complications following T&A in children with clinical SDB but with a pre-operative overnight home oximetry score of “normal/inconclusive” (McGill Oximetry Score (MOS) of 1), and to determine whether these children could safely undergo surgery in peripheral hospitals or outpatient surgical centers. Methods We performed a retrospective chart review of patients 3 years and older who had T&A between 2003 and 2010 at 2 of our institution’s hospitals. To be included in the study, in addition to not having severe comorbidities, children had to have undergone an overnight home oximetry within 12 months of surgery that was normal or inconclusive (MOS of 1). This was defined as fewer than 3 episodes of oxygen desaturation below 90% and stable baseline saturation over 95%. Medical charts were reviewed for major and minor postoperative respiratory complications. The main outcome measure was post-T&A respiratory complications. Results Out of 2708 T&A patients, 231 met the inclusion criteria. No patient had a major postoperative respiratory complication requiring re-intubation or admission to the intensive care unit. Five patients (2.16%) had minor respiratory complications but only one required admission to the ward. Conclusions An overnight home oximetry that is “normal/inconclusive” (MOS of 1) can be used as a screening tool to identify patients with sleep-disordered breathing who can be safely sent to peripheral hospitals or outpatient surgical centers for T&A.Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 10/2013; 42(1). DOI:10.1186/1916-0216-42-50 · 0.89 Impact Factor
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ABSTRACT: The diagnosis of sleep-disordered breathing in children has centered around polysomnography (PSG). While PSG is considered the gold standard for diagnosis of obstructive sleep apnea in children, the need for PSG before adenotonsillectomy is widely debated. An evidence-based clinical practice guideline on the use of PSG in children before tonsillectomy has recently been published. The recommendations contained in this guideline are discussed, emphasizing the appropriate indications for PSG as well as the limitations of existing evidence for the use of PSG and diagnosis of sleep-disordered breathing in children.Otolaryngology Head and Neck Surgery 11/2011; 146(2). DOI:10.1177/0194599811429236 · 2.02 Impact Factor