CHICAGO – Adenotonsillectomy improved both sleep and behavior in a pair of studies presented at the Combined Otolaryngology Spring Meetings.
Children with either obstructive sleep apnea syndrome (OSAS) or mild sleep disordered breathing (SDB) demonstrated significantly improved scores on behavior measurements after adenotonsillectomy, compared with presurgery scores, which suggests that symptom severity does not affect improvement, said Dr. Ron B. Mitchell, a pediatric laryngologist at Virginia Commonwealth University in Richmond.
Of 40 children aged 3–18 years, 23 had OSAS and 17 had SDB; demographics were similar between the two groups. The mean apnea-hypopnea index prior to surgery was 25 among the children with OSAS and 3 among those with SDB.
At a follow-up evaluation an average of 3 months after an adenotonsillectomy, children in both the OSAS and SDB groups showed significant improvements, compared with presurgery scores on the Behavior Symptom Index, a global measure of behavior. Differences in postsurgery scores between the two groups were not significant, however.
In addition, scores on the Behavior Assessment System for Children subscales of depression, hyperactivity, atypicality, and somatization were significantly improved after surgery, compared with presurgery scores for children in both groups, and the scores did not differ significantly between the groups.
All children had been measured with polysomnography and had undergone comprehensive behavior assessments prior to surgery. Children with comorbidities were excluded. The study was limited by the absence of a control group, the short follow-up period, and the selection bias inherent in the use of a population at a specialized clinic for sleep problems.
“Without a control group, all we can say is that adenotonsillectomy and improved behavior were associated, not necessarily correlated,” said Dr. Mitchell.
However, the study suggests that SDB is associated with a significant amount of behavioral morbidity regardless of the severity of the condition, and that these problems improve after adenotonsillectomy regardless of whether the child has only mild SDB or OSAS, he said.
In a second study of children with SDB, the 71 for whom follow-up data were available showed significant improvement in both sleep and behavior based on the pediatric sleep questionnaire (PSQ) and the Conners' Parent Rating Scale-Revised (CPRS-RS).
In addition, Dr. Julie Wei and her colleagues at the University of Kansas in Kansas City examined whether children whose scores were worse prior to surgery show greater benefit after surgery.
“We wanted to explore whether the improvements were a function of the baseline scores,” said Dr. Wei.
The prospective study included children aged 3–17 years, with a mean age of 6.5 years, who were evaluated using the PSQ and CPRS-RS.
Six months after the surgery, the average scores on the questionnaires improved significantly, compared with scores prior to surgery, especially among the children with the worst scores. “There was almost a 20-point reduction among the children who were worse to begin with,” Dr. Wei said.
The CPRS-RS evaluated the children's behavior in four categories: opposition, cognitive/inattention, hyperactivity, and the Conners' ADHD index. A score of 60 in any category would place a child at risk for problems in that category, Dr. Wei said. Before surgery, the mean scores in these categories were 59.4, 59.5, 62, and 59.9, respectively; after surgery, the mean scores were 51, 51.2, 52.4, and 50.6, respectively.
The children were clinically evaluated for SDB based on the 22-item pediatric sleep subscale of the 74-item PSQ, rather than polysomnography. The subscale has been shown to accurately predict SDB.
Although polysomnography is the approved measure of SDB, it is not available in all areas, and is used rarely. “Less than 5% of children have polysomnography prior to surgery,” Dr. Wei said.
The PSQ questionnaire can be a useful screening tool to determine candidacy for surgery as an adjunct to a history and physical exam, especially in areas where polysomnography is not available, Dr. Wei said.
The results of this study suggest that treatment of children who are diagnosed clinically using the pediatric sleep subscale show improved behavior and sleep even if their diagnosis is not confirmed by polysomnography, she said. The study was limited by the lack of a control group, the lack of data on behavior at school, and the use of a convenient sample of children with sleep problems. The evidence supported findings from previous research, including a study in which children with ADHD who underwent adenotonsillectomies no longer met ADHD criteria 1 year later (Pediatrics 2006;117:e769–e778).