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.
"Approximately 2000 years ago, Aulus Cornelius Celsus, a Roman writer and physician, described tonsil surgery by using his fingers to remove tonsils (Koempel et al., 2006; Younis and Lazar, 2002). Today, 530,000 children under the age of 15 have theirs tonsils or adenoids removed in the US every year and it is still one of the most common surgical procedures in children in this country (Cullen et al., 2009; Roland et al., 2011). The first attempt to nasally vaccinate humans against smallpox was reported in the Golden Mirror of Medicine, Chinese medical text in 1742. "
[Show abstract][Hide abstract] ABSTRACT: The olfactory organs of vertebrates are not only extraordinary chemosensory organs but also a powerful defense system against infection. Nasopharynx-associated lymphoid tissue (NALT) has been traditionally considered as the first line of defense against inhaled antigens in birds and mammals. Novel work in early vertebrates such as teleost fish has expanded our view of nasal immune systems, now recognized to fight both water-borne and air-borne pathogens reaching the olfactory epithelium. Like other mucosa-associated lymphoid tissues (MALT), NALT of birds and mammals is composed of organized lymphoid tissue (O-NALT) (i.e., tonsils) as well as a diffuse network of immune cells, known as diffuse NALT (D-NALT). In teleosts, only D-NALT is present and shares most of the canonical features of other teleost MALT. This review focuses on the evolution of NALT in vertebrates with an emphasis on the most recent findings in teleosts and lungfish. Whereas teleost are currently the most ancient group where NALT has been found, lungfish appear to be the earliest group to have evolved primitive O-NALT structures.
"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  "
"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). "
[Show abstract][Hide abstract] 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.
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.
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.
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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