Oral Session 2
Saturday, April 28, 2018 | 4:00pm-5:30pm | Room 342B
TONSILLECTOMY OUTCOMES FOR MORBIDLY OBESE CHILDREN WITH OBSTRUCTIVE SLEEP APNEA
Norman R. Friedman (USA)*
Amanda Ruiz (USA)
Jackson D. Kloor (USA)
Jordyn K. Dinwiddie (USA)
Dexiang Gao (USA)
Todd Wine (USA)
Pediatric obesity is a significant risk factor for the development of obstructive sleep apnea (OSA). For children, tonsillectomy and adenoidectomy (T&A) is the primary treatment for OSA. The only randomized clinical trial evaluating T&A surgical outcomes (CHAT) excluded children with morbid obesity. Forty-eight percent of the CHAT surgical cohort were obese or overweight. The T&A success rate for obese children was 67% compared to 85% for the non-obese cohort. The objective of this investigation was to determine the surgical success of T&A for morbidly obese (MO) children to facilitate shared decision dialogue with families on whether surgery or non-surgical options should be first line treatment.
Materials and methods
Retrospective chart review of MO children (BMI% for age > 99%) between 2-17 years of age who underwent a T&A from January 2015 through December 2016. Children with preoperative and postoperative polysomnograms (PSG) within 6 months of surgery were included in the analysis. Preoperative OSA severity was categorized as follows, Mild=2.0-4.9 obstructive events/hour; Moderate=5.0-9.9; Severe= ≥10.0. Demographic and clinical variables included age, ethnicity, comorbidities and tonsil size. The PSG metrics collected were sleep architecture, obstructive apnea/hypopnea index (OAHI), central apnea index, oxygen saturation nadir, percent sleep time with saturations less than 90% and mean end-tidal carbon dioxide (ETCO2).
Patient characteristics were summarized with descriptive statistics. The efficacy of T&A for OSA was tested multiple ways. First, the change in PSG parameters were analyzed with paired sample t-tests. Second, the number of subjects with surgical “cure” was quantified by OAHI <2 events/hour.
Forty MO children met inclusion criteria. The cohort included 26 males and 14 females with mean age of 8.8 years (± 4.1 years), range of 2.1-17.6 years. Preoperative OSA severity was as follows, mild = 4/40; moderate = 5/40; severe = 31/40. Forty percent (16/40) were cured with an OAHI < 2 events/h. Only one child had a categorical worsening of their obstruction. Nine remained in the same category of which 7 had severe and 2 had moderate OSA preoperatively. There was no association with tonsil size and surgical success. Overall, tonsillectomy resulted in significant improvements in multiple respiratory parameters, including OAHI (OAHI; 27.0 ± 34.8 to 7.7 ± 16.5, P < .001), percent sleep time with oxygen saturations < 90% (9.7 ± 18.4 to 2.1 ± 6.4, P =0.009), and saturation nadir (78.6 ± 9.5 to 84.0 ± 4.2, P < .001). There was no change in the mean EtCO2 (39.3 ± 4.1 to 39.8 ± 3.1, P =0.60). Of those with severe OSA, 32% (10/31) were cured with a postoperative OAHI < 2 events/hour but 22% (7/31) had no categorical improvement.
Tonsil surgery for a MO child is less likely to be successful. Due to its low cure rate, one should discuss non-surgical options preoperatively. Although a T&A is frequently non-curative, we do not know if a T&A may optimize the success of non-surgical options by improving baseline airway patency.