The effects of tonsillectomy and adenoidectomy on pulmonary arterial pressure in children

doi:10.1016/j.amjoto.2004.06.008

American Journal of Otolaryngology

Volume 26, Issue 1, January–February 2005, Pages 18-21

https://doi.org/10.1016/j.amjoto.2004.06.008 Get rights and content

Abstract

Purpose

It is well known that hypertrophic tonsils and adenoids may cause upper-airway obstruction. The aim of this study is to determine the mean pulmonary arterial pressure (mPAP) in children with hypertrophic tonsils and adenoids and to clarify whether tonsillectomy and adenoidectomy (T&A) has any effect on mean pulmonary arterial pressure of these children.

Materials and methods

Fifty-two randomly selected children (36 male, 16 female) aged between 4 and 11 (mean 7.7 ± 2.5) a with a diagnosis of upper-airway obstruction resulting from hypertrophied tonsils and adenoids were included in our study. Thirty-three children were assigned as controls with similar age and sex distrubution with the study groups. Mean pulmonary arterial pressure was measured by using Doppler echocardiography preoperatively and mean 5.4 ± 2.9 months postoperatively in all subjects.

Results

When the mean pulmonary arterial pressure values of study and control group compared preoperatively, the mean pulmonary arterial pressure levels of the children in the study group were significantly higher than the mean pulmonary arterial pressure levels of the children in the control group (P < .05) (study group mean PAP = 23.13 ± 7.68, control group mean PAP = 16.11 ± 7.24) (Levene’s test, P < .05). When the preoperative and postoperative results were compared, it was found that there was a statistically significant decrease in mean pulmonary arterial pressures in these 52 children (preoperative mean PAP = 23.13 ± 7.68, postoperative mean PAP = 17.00 ± 6.99) (paired sample t test, P < .05). Twenty-seven of the 52 subjects in the study group were pulmonary hypertensive preoperatively. mPAPs of 18 of these children decreased to normal range yielding 9 subjects, and this was also found ststistically significant (McNemar test, P < .001).

Conclusion

This study showed that obstructive adenoid and tonsillar hypertrophy causes higher mPAP values in children and revealed that T&A is an effective therapeutic measure in such patients.

Section snippets

Materials and methods

The study population was randomly selected from children who were referred to Department of Otolaryngology–Head and Neck Surgery at Afyon Kocatepe University Faculty of Medicine. Subjects having the following criteria were included in the study.

1.
Children with no chronic disease.
2.
Obstructive symptoms such as long lasting nocturnal snoring, sleep apnea, open mouth breathing, difficulty in swallowing, and poor appetite.
3.
Hypertrophic tonsils causing oropharyngeal airway obstruction. A standardized

Results

Thirty-one (59%) children out of 52 were found to have OSA in the study group preoperatively. In the control group, 3 children had a history of snoring and difficulty in breathing; however, none of them had a history of apneas. The mPAPs of 27 (51%) children were over 20 mmHg in the study group preoperatively. Twenty-three of the 27 children had OSA. After T&A, the mPAPs of 9 (17%) children were still above 20 mmHg; however, we observed a decrease in mPAP values in all these 9 children. In the

Discussion

Hypertrophic tonsils and adenoids are believed to lead to increased mPAP, pulmonary hypertension, and cor pulmonale [12], [13] by causing chronic upper airway obstruction. Pharyngeal obstruction caused by TAH disturbs the airflow coming from the nose, which has a laminar flow pattern, and this impairs the physiologic ventilation of the lungs [12]. Because the usual route of airflow is via the nasal passage, upper airway resistance is rised to increase nasal airflow, finally resulting in upper

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Association and risk factors of pediatric pulmonary hypertension with obstructive sleep apnea: A national study utilizing the Kids' Inpatient Database (KID)
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Assess the prevalence of and risk factors for pediatric pulmonary hypertension (PH) in the 2016 Kids' Inpatient Database (KID), including obstructive sleep apnea (OSA) and obesity.
Retrospective cross-sectional cohort study utilizing 6,081,132 weighted pediatric discharges from the 2016 KID. Study variables included age, length of stay, mortality, gender, hospital region, primary payer, race, median household income for patient's ZIP code, OSA, central sleep apnea (CSA), obesity, Down syndrome, sickle cell disease (SCD), thalassemia, congenital heart disease (CHD), hypertension, asthma and chronic lung disease of prematurity (CLDP). PH was the primary outcome of interest. Bivariate and multivariable logistic regression models were utilized with odds ratios and 95 % confidence intervals.
The mean age was 3.76 years, the mean hospital length of stay was 3.85 days, 48.9 % were male, 52.6 % had government health insurance, 51.0 % were White, 16.1 % were Black, 21.1 % were Hispanic, 5.0 % were Asian or Pacific Islander, 0.80 % were Native American and 6.1 % identified as “other”. The prevalence of PH was 0.21 % (12,777 patients). There were 37,631 patients with OSA and the prevalence of PH among this cohort was 3.3 %, over 10x greater than the overall prevalence of PH in the 2016 KID (0.21 %). Risk factors associated with PH included CLDP, CHD, Down syndrome, asthma, OSA, CSA, hypertension, SCD, obesity, race/ethnicity, government insurance, age, male gender (p < 0.0001), and hospital region (p = 0.0002).
Several risk factors were independently associated with PH, such as OSA, CSA, obesity, asthma, and insurance status. Prospective multi-institutional studies are needed to assess the relationships between these risk factors, severity metrics, and causative links in the development of PH; in addition to identifying children with OSA who are most likely to benefit from cardiopulmonary screening prior to adenotonsillectomy.
Level III.
Low incidence of pulmonary hypertension in children with suspected obstructive sleep apnea: A prospective observational study
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Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity.
A prospective study of children aged 1–13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1–2 (mild-moderate) and MOS 3–4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded.
One hundred and seventy children median age 3.8 years (IQR 2.7–6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH.
PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.
Current understanding of the role of sleep-disordered breathing in pediatric pulmonary hypertension
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Sleep-disordered breathing is a potentially reversible cause of pulmonary hypertension. Additionally, sleep-disordered breathing importantly contributes to disease severity in individuals with all causes of pulmonary hypertension. The co-existence of pulmonary hypertension and sleep-disordered breathing must be recognized as it may alter treatment strategies.
Here, we aim to describe the overlap between sleep-disordered breathing and pulmonary hypertension with a focus on infants and children. We will review the available literature regarding the prevalence of co-occurrence, the described pathophysiology, as well as the presentation, diagnosis, and management considerations for sleep-disordered breathing in the setting of pulmonary hypertension.
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  Pulmonary hypertension is a described complication of sleep-disordered breathing, though the prevalence of co-occurrence in children is not well studied.
- 2.
  Apneas and hypopneas cause rapid pleural pressure changes, hypoxia, and sympathetic nerve activation that lead to increased mean pulmonary artery pressure.
- 3.
  Obstructive sleep apnea must be identified and treated aggressively if pulmonary hypertension is present.
The effects of adeno/tonsillectomy on cardiopulmonary function based on echocardiography indices in children with primary snoring and mild obstructive sleep apnea
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The goal of this study was to evaluate the effects of adenotonsillectomy on heart function based on echocardiography indices in children with primary snoring (PS) and mild obstructive sleep apnea due to adenotonsillar hypertrophy (ATH).
55 children (aged 7 to 11 years old) with PS and ATH who were a candidate for adenotonsillectomy from August 2018 to June 2019 evaluated. A history of Upper Respiratory Tract Obstruction was obtained, clinical examination was performed and the cases suspicious for moderate to severe degrees of Obstructive Sleep Apnea Syndrome were excluded. Echocardiography was performed one week before and 3–6 months after surgery. All data were analyzed by SPSS version 19 and P-value<0.05 was considered significant.
From 55 enrolled cases, 42 [30 boys (71.5%) and 12 girls (28.5%)] completed the study course. Tricuspid Annular Plane Systolic Excursion (TAPSE), Ejection Fraction (EF), Right Ventricular Peak Systolic Myocardial Velocity (RVSM), Right Ventricular Fractional Area Change (RVFAC) were increased significantly and Isovolumic Contraction Time (IVCT) index was decreased significantly after surgery (P-value<0.05). The difference of indices between the two sexes was not significant after surgery (P-value>0.05).
Adenotonsillectomy can improve cardiac function indices in patients with PS due to ATH especially in terms of right ventricle (RV) function and reduction in pulmonary artery pressure. So, although “subclinical”, it is better to be considered PS not just as annoying noise for roommates before significant clinical cardiac problems happen.
Prevalence of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy: A meta-analysis
2022, International Journal of Pediatric Otorhinolaryngology
Adenoid or adenotonsillar hypertrophy (AATH) adversely affects cardiovascular function, leading to pulmonary hypertension (PH). This meta-analysis of observational studies aimed to estimate the prevalence of PH in children with AATH.
A meta-analysis was performed by searching the PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from their inception to 1 July 2021, for all studies that extracted data about PH prevalence in children with AATH. PH prevalence was calculated for each included study and as a pooled estimate with a 95% confidence interval.
A total of eight studies were included in this analysis. The pooled prevalence of PH in children with AATH was 35.0% (95% CI [18.0%, 52.0%]). The subgroup analysis demonstrated that the prevalence of PH in children with adenotonsillar hypertrophy was higher than that with adenoid hypertrophy with or without tonsillar hypertrophy (39.0%, 95% CI [14.0%, 65.0%] vs. 22.0%, 95% CI [17.0%, 28.0%], respectively). The prevalence derived from the prospective and cross-sectional studies were 45.0% (95% CI [13.0%, 76.0%]) and 20.0% (95% CI [14.0%, 25.0%]), respectively. America and Africa had lower prevalence rates than Asia (24.0%, 95% CI [1.0%, 46.0%], 27.0%, 95% CI [17.0%, 38.0%], and 48.0%, 95% CI [-2.0%, 98.0%]), respectively. The prevalence of studies with diagnostic criterion (a mean pulmonary artery pressure higher than 20 mmHg) was 50.0% (95% CI [6.0%, 94.0%]). The pooled prevalence of studies with diagnostic criterion (a mean pulmonary artery pressure higher than 25 mmHg) was 25.0% (95% CI [13.0%, 36.0%]).
The meta-analysis showed a prevalence of PH in children with AATH of 35.0%, demonstrating that this condition is a frequent complication of AATH. To better understand its clinical impact, more prospective evaluations are urgently needed.
The systolic pulmonary artery pressure and the E/e’ ratio decrease after septoplasty in patients with grade 2 and 3 pure nasal septal deviation
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Nasal septal deviation may contribute to a wide range of symptoms including nasal obstruction, headache, increased secretion, crusting, mucosal damage, and loss of taste and smell. Excessive increase in the respiratory resistance, as seen in nasal septal deviation, results in reduced lung ventilation, thereby potentially leading to hypoxia, hypercapnia, pulmonary vasoconstriction. The deformities in the nasal cavity can be associated with major respiratory and circulatory system diseases.
To investigate cardiovascular effects of septoplasty by comparing pre- and postoperative transthoracic echocardiography findings in nasal septal deviation patients undergoing septoplasty.
The prospective study included 35 patients with moderate and severe nasal septal deviation (mean age, 23.91 ± 7.01) who underwent septoplasty. The Turkish version of the nasal obstruction symptom evaluation, NOSE questionnaire, was administered to each participant both pre- and postoperatively in order to assess their views on the severity of nasal septal deviation, the effect of nasal obstruction, and the effectiveness of surgical outcomes. A comprehensive transthoracic echocardiography examination was performed both preoperatively and at three months postoperatively for each patient and the findings were compared among patients.
Mean preoperative NOSE score was 17.34 ± 1.62 and the mean postoperative score was 2.62 ± 1.68 (p = 0.00). Mean preoperative systolic pulmonary artery pressure value was 22.34 ± 4.31 mmHg and postoperative value was 18.90 ± 3.77 mmHg (p = 0.00). Mean E/e’ ratio was 5.33 ± 1.00 preoperatively and was 5.01 ± 0.90 postoperatively (p = 0.01). The NOSE scores, systolic pulmonary artery pressure values, and the E/e’ ratios decreased significantly after septoplasty (p < 0.05 for all), whereas no significant difference was found in other transthoracic echocardiography parameters (p > 0.05).
The decrease in NOSE scores following septoplasty indicated that the satisfaction levels of the patients were increased. Upper airway obstruction secondary to nasal septal deviation may be a cardiovascular risk factor and may affect transthoracic echocardiography measurements. Moreover, the significant decrease in the systolic pulmonary artery pressure value and E/e’s ratio following septoplasty indicated that negative echocardiographic findings may be prevented by this surgery.

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^☆: Presented at the 27th meeting of Turkish Society of Otolaryngology Head and Neck Surgery, October 4-9, 2003, Antalya, Turkey.

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The effects of tonsillectomy and adenoidectomy on pulmonary arterial pressure in children☆

Abstract

Purpose

Materials and methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr.

Am. J. Cardiol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr.

Reversible cor pulmonale due to hypertrophied tonsils and adenoids: studies in two cases

Circulation

Hypoventilation and cor pulmonale due to chronic upper airway obstruction

J. Pediatr.

Respiratory obstruction caused by acute tonsillitis and adenoiditis

New York J. Med.