The effect of adenotonsillectomy on right ventricle function and pulmonary artery pressure in children with adenotonsillar hypertrophy

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Abstract

Objectives

Adenotonsillar hypertrophy (ATH) is the most common cause of upper airway obstruction in children. Severe upper airway obstruction may have an effect on chronic alveolar hypoventilation, which consequently may lead to right ventricle (RV) dysfunction induced by hypoxemic pulmonary vasoconstriction. The investigators aimed to study RV function and mean pulmonary artery pressure (mPAP) in patients with ATH who were undergoing adenotonsillectomy by using tissue Doppler echocardiography (TDE).

Methods

The study examined 27 children with ATH who had a mean age of 8 ± 2 years. The subjects were comprised 17 (63%) males and 10 (37%) females. Hypertrophy of the tonsils was graded according to the Brodsky scale. Children having either grade 3 or 4 hypertrophied adenotonsils were recruited for the study. Adenotonsillectomy was performed on all subjects in the study group and echocardiographic examination was repeated 3 months postoperatively.

Results

Tricuspid Em significantly increased after adenotonsillectomy (17.7 ± 3.6 vs. 19.1 ± 5.5, p = 0.04). The RV myocardial performance index (MPI) and mPAP significantly decreased after adenotonsillectomy (RV MPI: 0.57 ± 0.13 vs. 0.40 ± 0.12, p < 0.001 and mPAP (mm Hg): 31 ± 9 vs. 25 ± 7, p = 0.001).

Conclusion

The results of this study, evaluated with the results of previous studies, demonstrated that adenotonsillectomy improved RV performance and reduced mPAP in children with ATH.

Introduction

Adenotonsillar hypertrophy (ATH) is an important health condition, and is seen especially during childhood. The relationship between ATH and other diseases such as cardiovascular and pulmonary disorders was reported in previous studies [1], [2], [3], [4]. It is well known that ATH is one of the most common causes of upper respiratory tract obstruction, obstructive sleep apnea (OSA) and hypoxia in children [2]. Severe upper respiratory tract obstruction may have an effect on chronic alveolar hypoventilation, which consequently may lead to right ventricle (RV) dysfunction induced by hypoxemic pulmonary vasoconstriction. This RV dysfunction may result in increased pulmonary vascular resistance and pulmonary artery pressure (PAP) [5]. Echocardiography is one of the most important noninvasive methods to diagnose for structural heart disease in children [6]. Previous conventional echocardiography studies have shown that upper respiratory tract obstruction causes pulmonary hypertension (PH) and right ventricle (RV) dysfunction [2], [7], [8], [9], [10], [11], [12]. Although the standard test for the evaluation of pulmonary artery pressure is performed by highly invasive cardiac catheterization, Doppler echocardiography has been demonstrated to have a perfect correlation with cardiac catheterization [13], [14]. Tissue Doppler echocardiography (TDE) also gives more detailed quantitative information about myocardial function compared with conventional echocardiography [6].

In the current study, the investigators aimed to study RV function and mean pulmonary artery pressure (mPAP) in patients with ATH who were undergoing adenotonsillectomy by using TDE.

Section snippets

Study population

A prospective trial was performed on children with ATH. The study was approved by The Ethics Committee of Erciyes University, Medical Faculty. Twenty-seven children with ATH were selected from children admitted to the clinic with complaints of snoring, mouth breathing, pausing of breathing during sleep and recurrent adenotonsillar infection for at least 6 months. All children underwent a complete ear–nose–throat (ENT) examination and flexible nasopharyngoscopy in appropriate cases for additional

Hypertrophy of tonsils

Baseline characteristics of the children are shown in Table 1. The study patients consisted of a total of 27 children, 17 (63%) males and 10 (37%) females aged 8 ± 2 years. Hypertrophy of the tonsils was graded according to the Brodsky scale and it was found that 44% of children were grade III and 56% were grade IV.

The Echocardiographic findings

The echocardiographic findings of the study are presented in Table 2. Tricuspid Em significantly increased after adenotonsillectomy (p = 0.04). At the postoperative term, the Em value

Discussion

The main finding of the present study was that TDE-derived RV MPI and mPAP levels were significantly decreased in patients with ATH undergoing adenotonsillectomy. Pulmonary vascular disease may result in elevated resting pulmonary artery pressures and increases in pulmonary artery pressure with exertion. ATH may stimulate PH due to the vasoconstrictive effects of hypoxia and hypercarbia. The vasodilative effects of normoxia after adenotonsillectomy may decrease the levels of mPAP and RV MPI.

Conclusion

The results of this study, evaluated with the results of previous studies, demonstrated that adenotonsillectomy improves RV performance and reduces mPAP in children with ATH. However, further studies with a greater sample size and different approaches are needed to find the mechanistic pathways of these observations.

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