Adenotonsillar Disease/ Obstructive Sleep Apnea

Back To Search

Adenotonsillar Disease/ Obstructive Sleep Apnea

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, Florida

Module Summary

Adenotonsillar disease is one of the most common reasons children seek otolaryngologic care. This accumulation of lymphoid tissue around the entrance to the upper aerodigestive tract may be affected by enlargement due to cellular hyperplasia, recurrent or chronic infections, or neoplasm. Treatment options range from medical options in an effort to treat infections or shrink enlarged lymphoid tissue, or surgery to remove the offending tissue. Manifestations of long standing upper airway obstruction due to obstructive sleep apnea (OSA) must be anticipated, as well as the risk of residual OSA following surgery in some patients.

Module Learning Objectives 
  1. Identify common pathologies affecting adenotonsillar tissue in children.
  2. Describe the diagnosis and medical management of common adenotonsillar diseases.
  3. Explain surgical treatment of adenotonsillar disease in children.

 

Anatomy

Learning Objectives 

Recognize the specific accumulations and collections of lymphoid tissue within Waldeyer’s ring in the upper aerodigestive tract.

References 
  1. Goldstein NA,Tomaski, SM. Embryology and Anatomy of the Mouth, Pharynx, and Esophagus. Chapter 50. In:Pediatric Otolaryngology, 4th ed. Bluestone CD, et al. Philadelphia:Saunders:1095-1096.

Pathogenesis

Learning Objectives 
  1. Recognize the etiology of infectious diseases of the adenoids and palatine tonsils.
  2. Recognize the implications of enlargement of lymphoid tissue within Waldeyer’s ring.

 

References 
  1. Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Rockette HE, Kurs-Lasky M. Tonsillectomy & adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002;110(1):7-15
  2. Discolo CM, Darrow DH, Koltai PJ. Infectious indications for tonsillectomy. Pediatr Clinics North Am. 2003;50:445-458.
  3. Sterni LM, Tunkel DE. Obstructive sleep apnea in children; an update. Pediatr Clinics North Am. 2003;50:427-443.

Basic Science

Learning Objectives 

Describe the physiologic function of lymphoid tissue in the upper aerodigestive tract. 

Incidence

Learning Objectives 
  1. Describe the incidence of recurrent adenotonsillitis in children.
  2. Describe the incidence of snoring and obstructive sleep apnea in children.
References 
  1. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol. 1990;99:187-191.
  2. R. Wald, Eric Wall, Gemma Sandberg and Milesh M. Patel, Darrow, Terri Giordano, Ronald S. Litman, Kasey K. Li, Mary Ellen Mannix, Richard H. Schwartz, Gavin Setzen, Ellen Reginald F. Baugh, Sanford M. Archer, Ron B. Mitchell, Richard M. Rosenfeld, Raouf Amin, James J. Burns, David H. Clinical Practice Guideline:Tonsillectomy in Children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30.

Patient Evaluation

Learning Objectives 
  1. To identify patient factors in the history and physical examination that indicate recurrent adenotonsillitis which is pathologic.
  2. To identify patient factors in the history and physical examination that indicate the presence of upper airway obstruction related to enlargement of adenotonsillar tissue.

 

References 
  1. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical Practice Guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1S):S1-S15.
  2. Statham MM, Elluru RG, Buncher R, Kalra M. Adenotonsillectomy for obstructive sleep apnea in young children; prevalence of pulmonary complications. Arch Otolaryngol Head Neck Surg. 2006;132(5):476:480.
  3. Hartnick CJ, Ruben RJ. Preoperative coagulation studies prior to tonsillectomy. Arch Otolaryngol Head Neck Surg. 2000;126(5):684-686.
  4. Kay DJ, Mehta V, Goldsmith AJ. Perioperative adenotonsillectomy management in children; current practices. Laryngoscope. 2003;113:592-597.

Measurement of Functional Status

Learning Objectives 

Recognize the end organ and functional deficits caused by untreated OSA in children. 

 

References 
  1. Tran KD, Nguyen CD, Weedon J, Goldstein NA. Child behavior and quality of life in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005;131:52-57.
  2. Mitchell RB, Kelly J. Behavior, neurocognition and quality-Of -life in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol. 2006;70:395-406.
  3. Katz ES, Moore RH, Rosen CL, et al. Growth after adenotonsillectomy for obstructive sleep apnea: an RCT. 2014;134(2):282-289.
  4. Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 2006;117(4):e769-778.

Pathology

Learning Objectives 
  1. Recognize the development of pathologically abnormal recurrent adenotonsillar infections.
  2. Recognize the development of pathologic enlargement of adenotonsillar tissue and its effects of respiration and deglutition.

 

References 
  1. Younis RT, Hesse SV, Anand VK. Evaluation of the utility and cost-effectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens. Laryngoscope. 2001;111:2166-2169.
  2. Strong EB, Rubinstein B, Senders CW. Pathologic analysis of routine tonsillectomy and adenoidectomy specimens. Otolaryngol Head Neck Surg. 2001;125:473-477.

Treatment

Learning Objectives 

Identify potential therapeutic options for pathologic disease of the tonsils and adenoids.

 

References 
  1. Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children; results of parallel randomized and non-randomized clinical trials. New Engl J Med. 1984;310:674-683.
  2. Paradise JL, Bluestone CD, Colborn DK, Bernard BS, et al. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002;110:7-15.
  3. Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134:979-984.
  4. Friedman M, Wilson M, Lin HC, Ching HW. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2009;140(6):800-808.

Medical Therapies

Learning Objectives 
  1. Identify antimicrobial therapeutic options for infectious disorders of adenotonsillar tissue.
  2. Identify medical therapies which can result in a decrease in the size of the adenoids and tonsils.

 

References 
  1. Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122(1):e149-155.
  2. Zhang, L, Mendoza-Sassi RA, Cesar JA, Chadha NK. Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008(3):CD006286.
  3. Kheirandish-Gozal L, Bhattacharjee R, Bandla HP, Gozal D. Anti-inflammatory therapy outcomes for mild OSA in children. Chest. 2014;146(1):88-95.

Pharmacology

Learning Objectives 

Describe the mechanism of action of nasal steroids and how they can result in a decrease in adenoid size. 

 

References 
  1. Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122(1):e149-155.
  2. Zhang, L, Mendoza-Sassi RA, Cesar JA, Chadha NK. Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 (3):CD006286.

Surgical Therapies

Learning Objectives 
  1. Describe the surgical indications for performing adenotonsillectomy.
  2. Perform an adenotonsillectomy step-by-step.
  3. Understand the advantages and disadvantages of different surgical instruments commonly used to perform adenotonsillectomy.

 

References 
  1. Younis RT, Lazar R. History and current practice of tonsillectomy. Laryngoscope. 2002;112(suppl 100):3-5.
  2. Koltai PJ, Solares CA, Koempel JA, Hirose K, et al. Intracapsular tonsillar reduction (partial tonsillectomy); reviving a historical procedure for obstructive sleep disordered breathing in children. Otolaryngol Head Neck Surg. 2003;129(5):532-538.
  3. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope. 2002;112(suppl 100):6-10.
  4. Maddern BR. Electrosurgery for tonsillectomy. Laryngoscope. 2002;112(suppl 100):11-13.
  5. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical Practice Guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1S):S1-S15.
  6. R. Wald, Eric Wall, Gemma Sandberg and Milesh M. Patel, Darrow, Terri Giordano, Ronald S. Litman, Kasey K. Li, Mary Ellen Mannix, Richard H. Schwartz, Gavin Setzen, Ellen Reginald F. Baugh, Sanford M. Archer, Ron B. Mitchell, Richard M. Rosenfeld, Raouf Amin, James J. Burns, David H. Clinical Practice Guideline:Tonsillectomy in Children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30.

Case Studies

  1. A 3 year old male with an unremarkable past medical history presents with parental complaints of snoring every night for the last 4 months, chronic open mouth breathing, and witnessed pauses during sleep, which have been noted 2-3 times per week over the last month. Physical examination revealed a normal appearing child, with slightly pursed lips, and 3+ tonsils. What further workup is indicated? The parents ask about getting a polysomnogram. Can you explain the advantages, disadvantages, and indications for obtaining a polysomnogram?
  2. A 6 year old male with Down syndrome is referred for mild obstructive sleep apnea. His primary care physician has inititated no therapy thus far. What non-invasive therapeutic options are available to treat this child? At what point would surgery be indicated if non-invasive therapies did not work?

Complications

Learning Objectives 

Recognize common complications of adenotonsillectomy.

References 
  1. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. 1998;118(1):61-68.
  2. Johnson LB, Elluru RG, Myer CM. Complications of adenotonsillectomy. Laryngoscope. 2002;112(suppl 100):35-36.
  3. Cressman WR, Myer CM. Management of tonsillectomy hemorrhage; results of a survey of pediatric otolaryngology fellowship programs. Am J Otolaryngol. 1995;16(1):29-32.

Review

Review Questions 
  1. What are the most common indications for adenotonsillectomy in children?
  2. What factors in the clinical evaluation are most suggestive of the presence of underlying OSA?
  3. What are the sequelae of untreated OSA?
  4. What are the most common complications of adenotonsillectomy?
Resources 

Learner must Sign In to access AAO-HNSF education activities.

  1. Annual Meeting Webcast (AMW):