Can sleep questionnaires predict adenotonsillectomy outcome for children with sleep disordered breathing?

INTRODUCTION: Adenotonsillar hypertrophy is the main cause of childhood sleep disordered breathing (SDB) and adenotonsillectomy (TA) the most common treatment. Polysomnography (PSG) for diagnosing SDB is often difficult to obtain with Otolaryngologists usually relying on history and examination when recommending TA. Questionnaires assessing quality of life (QoL) may assist the Otolaryngologists decision making. AIMS: To explore changes in QoL tools following TA for SDB in children aged 3 to 15 with the aim of identifying whether the Pediatric Sleep Questionnaire (PSQ) or Obstructive Sleep Apnoea -18 (OSA-18) is a better predictor of outcome following TA. METHODS: QoL was assessed using OSA-18, PSQ and the Pediatric Quality of Life Inventory™ (PedsQL™). Four groups were recruited from three research databases, those with: SDB, recurrent tonsillitis (RT), SDB and RT, or no disease (controls). Children either received TA or underwent observation. QoL questionnaires were administered at recruitment and 3 months later. Test-retest reliability was assessed using Bland-Altman plots. Pre-intervention scores were plotted against changes in scores, with pre-established cut-offs and cut-offs indicated by control group variability. RESULTS: There were 120 children, 25 had no intervention, and 19 were controls. All questionnaires showed test-retest reliability over time. Using the distribution of scores from the control group we estimated the 95th percentile to redefine the cut-off for OSA-18 (reduced from 60 to 46) and PSQ (unchanged from 0.33). Higher pre-operative scores predicted greater reduction following TA, with OSA-18 the most consistent predictor of QoL change. The PSQ classified 86.8% of children undergoing TA above the 0.33 cut-off; whereas OSA-18 classified 73.7% above the 46 cut-off. Of these, 71.2% and 87.5% showed improvement after TA, respectively. Using the 95% confidence interval for change in the control group to identify a 'meaningful' change in score, children with OSA-18 scores >46 had a 93% chance of a meaningful improvement, whereas PSQ scores >0.33 were associated with an 80% chance of a meaningful improvement. CONCLUSIONS: OSA-18 is a better predictor of improved QoL than PSQ for TA in children with SDB. We propose a new cut off score (>46) for OSA-18. This may assist Otolaryngologists' decision making when assessing a child with SDB.

Sleep-Related Breathing Problem Trajectories Across Early Childhood and Academic Achievement-Related Performance at Age Eight.

Background: Childhood sleep disordered breathing (SDB) has been linked to poorer academic performance; however, research has not investigated the extent improvement in SDB may alter outcomes across key academic skills. This study aimed to investigate if children's early SDB status could predict later academic outcomes, and if an improvement in SDB status across the early childhood years would coincide with better, later performance in key academic skills related to reading, numeracy, and listening comprehension. Methods: Eighty five case children with an SDB symptom score >25 (maximum 77) were matched to 85 control children (score <12) at recruitment (age 3). SDB severity (symptom history and clinical assessment) was evaluated at ages 3, 4, 6, and 8 years and performance on individually-administered academic skills assessed at age 8 (91% retention from age 3). Case children were categorized into "improved" or "not-improved" groups based on SDB trajectories over the 5 years. Contributions of SDB status and trajectory group to academic performance were determined using regression analysis adjusted for demographic variables. Results: History of SDB from age 3 predicted significantly poorer performance on some key academic skills (oral reading and listening skills) at age 8. Children whose SDB improved (45%) performed better in oral reading fluency than those whose SDB did not improve, but difficulties with specific tasks involving oral language (listening retell) remained when compared to controls. Conclusion: Findings support links between early SDB and worse academic outcomes and suggest key academic areas of concern around oral language. Findings highlight the need for child mental health professionals to be aware of children's sleep problems, particularly SDB (past and present), when assessing potential barriers to children's achievement, to assist with appropriate and timely referrals for evaluation of children's sleep difficulties and collaborative evaluation of response to intervention for sleep difficulties.

Emergent academic skills growth in New Zealand pre-school children undergoing treatment for sleep disordered breathing: a case-control pilot study.

OBJECTIVES: The main objective of this study was to explore the feasibility and treatment sensitivity of measures of preschool oral language and emergent literacy and numeracy for assessing developing skills of preschool children with sleep disordered breathing (SDB) in New Zealand following adenotonsillectomy. METHODS: Eight preschool children aged 3 years 1 month-4 years 5 months were recruited from a surgical waiting list and matched to controls for age (±3 months) and sex. Tasks designed to be sensitive to growth in oral language and emergent literacy and numeracy were reviewed for contextual fit, adapted as necessary for the New Zealand context, and administered before surgery (baseline), three months post-surgery, and at a seven-month follow-up alongside other measures. RESULTS: Growth in oral language and emergent literacy was greater for case children than matched controls, suggesting that the tasks were sensitive to treatment effects. No such effect was observed for early numeracy tasks. Case children had more symptoms of SDB and behavioral and emotional difficulties than matched controls prior to surgery, and improvements were reported in these domains following surgery. CONCLUSIONS: Oral language and emergent literacy measures trialled in the present research showed potential for evaluating treatment outcomes in pre-schoolers with SDB, and provided preliminary evidence that early treatment of SDB could have positive effects on learning in these domains.

Complications following frenotomy for ankyloglossia: A 24-month prospective New Zealand Paediatric Surveillance Unit study.

AIM: To investigate the incidence and characteristics of complications arising from frenotomy for ankyloglossia (tongue-tie) in New Zealand. METHODS: Prospective surveillance among hospital-based paediatricians of complications arising from frenotomy for ankyloglossia to children <1 year old was conducted by the New Zealand Paediatric Surveillance Unit for 24 months, from August 2016 to July 2018, inclusive. RESULTS: A total of 16 cases of complications arising from frenotomy were reported. The overall average annual incidence rate was 13.9/100 000. Geographic variation was noted with a peak of 85.6/100 000 in one region. Complications reported: poor feeding (44%), respiratory events (25%), pain (19%), bleeding (19%) and weight loss (19%). Three children (19%) also had delayed diagnosis of an underlying medical condition initially overlooked in favour of treating their ankyloglossia, this has not previously been reported. The majority (75%) of cases required admission to hospital. Treatments given included supplementary feeds (44%), surgical intervention (25%), breastfeeding support (19%), analgesia (13%) and blood products (13%). A total of 25% of children had one or more frenotomies; 50% were treated for two or more of: 'anterior' ankyloglossia, 'posterior' ankyloglossia or 'lip tie'; 50% had their frenotomies performed out of the hospital. Dentists were the most common performing practitioner (31%). CONCLUSIONS: Frenotomy rates in New Zealand are unknown. Poor feeding, pain, bleeding, weight loss and delayed diagnosis of an alternative underlying medical condition are important complications that require hospital assessment and admission. Practitioners and parents/families need to be aware of these possibilities. Centralised guidelines with access to specialist second opinions should be developed.

The use of pulse transit time in pediatric sleep studies: A systematic review.

As a surrogate measure of blood pressure, pulse transit time (PTT) is commonly used in studies investigating arterial function and respiratory sleep disturbance. A systematic search of the literature was conducted with the aim of reviewing the usefulness of the technique within pediatric sleep studies. All studies that used PTT as a diagnostic tool during sleep in infants, children or adolescents were considered. The search yielded 425 articles, of which 21 full-text articles met inclusion criteria, the majority reporting on obstructive sleep apnea (OSA). PTT was used alongside polysomnography (PSG) in all studies. Several studies supported the potential of PTT to detect central apneic events in both infants and children and obstructive events in children, with implications for use as a screening tool for OSA, albeit with some limitations. Only one study validated PTT against blood pressure (BP), and only against systolic arterial pressure (SAP), showing significant negative correlations between PTT and SAP. PTT tracked well against BP and heart rate (HR) over acute cardiovascular perturbations in several studies. PTT is simple to execute, cost-efficient to run, and more tolerable than alternatives to measuring continuous BP in children. However its potential as a core clinical tool remains to be determined.

Habitual Snoring at Age 3 Years: Links with Parent-Rated Remembering in Daily Life and Academic Achievement at Age 7 Years.

OBJECTIVE: Habitual snoring in school-aged children is well known to link with poorer cognitive functioning and academic performance, but few studies have explored later developmental outcomes related to snoring initiated in early childhood. The aims of this study were to examine whether habitual snoring at age 3 years predicted perceived memory and academic functioning at age 7 years. METHODS: Parents (n = 460) of children aged 7 years 2 ± 5 months completed a community follow-up survey about their perceptions of their child's sleep and health, memory in daily activities, and academic performance relevant to numeracy and literacy skills. The first survey was completed by 839 parents 4 years prior when children were aged 3 years (54.8% response rate at age 7 years). Parents rated their child's academic performance twice. First, they rated performance based on teachers' feedback relative to national standard ratings for numeracy and literacy, and second, based on their own observations. RESULTS: Children reported to snore habitually at age 3 years received lower memory and academic composite score ratings at age 7 years. Age 3 years habitual snoring history predicted small but significant unique variation in age 7 years memory (p = 0.005), literacy (p < 0.001), and overall achievement ratings (p = 0.016) in regressions controlling for covariates, with evidence suggesting that memory may mediate links between snoring history and academic performance. CONCLUSION: The findings suggest that habitual snoring in early childhood may adversely affect success in beginning schooling. More research is still needed to determine the best time for treatment so that longer-term consequences of sleep-disordered breathing may be prevented.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial.

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Gabapentin for Perioperative Analgesia in Otorhinolaryngology-Head and Neck Surgery: Systematic Review.

OBJECTIVE: Recent research has investigated the role of gabapentin in perioperative pain relief in otorhinolaryngology-head and neck surgery. This review aims to identify whether sufficient evidence exists for the routine use of gabapentin in the perioperative setting. DATA SOURCES: MEDLINE, Cochrane CENTRAL, EMBASE, and Google Scholar. REVIEW METHODS: A comprehensive systematic search was performed with keywords for articles up to November 2015. The systematic review included all randomized, placebo-, and active-controlled trials investigating the role of perioperative gabapentin for pain in otorhinolaryngology-head and neck surgery. The studies were assessed for risk of bias and selected and reviewed by the main author. Selected trials were required to have data in the form of pain intensity scores, analgesic consumption, adverse effects, or return to normal function. RESULTS: A total of 14 randomized controlled trials were included, of which 4 had an active control. The placebo-controlled trials included 4 for tonsillectomy, 3 for rhinology, and 3 for thyroidectomy. These studies were not suitable for meta-analysis. Trial quality involving gabapentin in tonsillectomy surgery is variable. The higher-quality studies reported significantly reduced analgesic consumption in the gabapentin groups, with the effect on pain scores less clear. There was a significant benefit, within the first 24 hours, in pain and analgesic consumption as compared with placebo favoring the gabapentin groups following rhinologic and thyroid surgery. CONCLUSION: Overall, gabapentin appears to have a significant beneficial effect on perioperative pain relief and analgesic consumption in otorhinolaryngology-head and neck surgery procedures within the first 24 hours.

Video head impulse in comparison to caloric testing in unilateral vestibular schwannoma.

CONCLUSIONS: Although there was a statistically significant relationship between the results of the vHIT and the caloric test, the limited strength of this relationship suggests that, for unilateral vestibular schwannoma (UVS), caloric testing and vHIT may provide complementary information on vestibular function. OBJECTIVE: There is limited information that can be used to determine which of the video head impulse test (vHIT) and caloric test might be better used in the diagnosis and management of UVS. In this study, a group of participants with un-operated UVS was studied using both methods. METHODS: The subjects' vestibular function was assessed using the vHIT and caloric testing. Tumour size was quantified using MRI and their balance disturbance assessed using the Jacobsen Dizziness Handicap Inventory (DHI). RESULTS: Twenty of 30 subjects had an abnormal canal paresis according to the Jongkees' criterion (> 0.25); however, only 10/30 had an ipsilesional vHIT gain of <0.79. Canal paresis could be predicted from the ipsilesional and contralesional vHIT gains. Tumour size could also be predicted from the ipsilesional vHIT gain and canal paresis. However, DHI scores could not be predicted from the degree of canal paresis, vHIT gain, or the MRI measures.

Sleep Disordered Breathing and Academic Performance: A Meta-analysis.

BACKGROUND AND OBJECTIVE: Sleep-disordered breathing (SDB) in children is associated with daytime functioning decrements in cognitive performance and behavioral regulation. Studies addressing academic achievement are underrepresented. This study aimed to evaluate the strength of the relationships between SDB and achievement in core domains and general school performance. METHODS: Data sources included PubMed, Web of Science, CINAHL, and PsycINFO. Studies of school-aged children investigating the relationships between SDB and academic achievement were selected for inclusion in a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extracted were converted into standardized mean differences; effect sizes (ES) and statistics were calculated by using random-effects models. Heterogeneity tests (I(2)) were conducted. RESULTS: Of 488 studies, 16 met eligibility criteria. SDB was significantly associated with poorer academic performance for core academic domains related to language arts (ES -0.31; P < .001; I(2) = 74%), math (ES -0.33; P < .001; I(2) = 55%), and science (ES -0.29; P = .001; I(2) = 0%), and with unsatisfactory progress/learning problems (ES -0.23; P < .001; I(2) = 0%) but not general school performance. CONCLUSIONS: Variable definitions of both academic performance and SDB likely contributed to the heterogeneity among published investigations. Clear links between SDB and poorer academic performance in school-age children are demonstrated. ES statistics were in the small to medium range, but nevertheless the findings serve to highlight to parents, teachers, and clinicians that SDB in children may contribute to academic difficulties some children face.

Natural history of snoring and other sleep-disordered breathing (SDB) symptoms in 7-year-old New Zealand children: a follow-up from age 3.

PURPOSE: We aimed to examine the natural history of snoring and associated symptoms in a community sample of New Zealand children at ages 3 and 7 years, and identify factors associated with habitual snoring at age 7 years. METHODS: Parent/s of children (n = 839) who completed the community survey about their child's sleep and breathing at age 3 years were re-contacted via mail 4 years later when children were aged 7 years. Parents were asked to complete a follow-up questionnaire which included items relating to their child's sleep and health, and family demographic information. There was a 54.8% (n = 460) response rate. RESULTS: At follow-up, habitual snoring was prevalent in 9.2% of the sample, similar to the 11.3% reported at age 3 years. However, habitual snoring status changed over time; 36.2% (n = 21/58) remained habitual snorers; 63.8% (n = 37/58) were no longer snoring habitually, while 5.3% (n = 21/397) had started habitual snoring since the initial survey. Overall, the reported severity of SDB-related symptoms decreased over time, regardless of initial habitual snoring status. Nonetheless, habitual snoring at follow-up was significantly associated with mouth breathing, sleeping with the neck extended, sweating profusely, night waking, and parent-reported child irritability. CONCLUSIONS: Our findings highlight the dynamic nature of SDB, where habitual snoring and related symptoms can develop, remain present, or resolve at different times, over early-mid-childhood years. Given the dynamic nature of habitual snoring over the early childhood years, pediatricians should continue to screen for snoring and sleep apnea on an annual basis throughout childhood.

Head and neck fascia and compartments: no space for spaces.

An accurate understanding of the arrangement of cervical fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The purpose of this detailed review is to summarize the anatomic, clinical, and radiological literature to determine what is known about the arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and compartments is replete with confusing synonyms and inconsistencies, creating important interdisciplinary differences in understanding. The term "spaces" is inappropriate. A modified nomenclature underpinned by evidence-based anatomic and radiologic findings is proposed. This should not only enhance our understanding of cervical anatomy but also facilitate clearer interdisciplinary communication.

Neurobehavioural correlates in older children and adolescents with obesity and obstructive sleep apnoea.

AIM: The relationship between obstructive sleep apnoea (OSA) and poorer neurobehavioural outcomes in school-age children is well established, but the relationship in obese children and adolescents, in whom OSA is more common, is not so well established. We aimed to investigate this relationship in 10-18-year-olds. METHODS: Thirty-one participants with a mean body mass index (BMI) of 32.3 ± 4.9 enrolled. BMI-for-age cut-offs were used to define obesity. Participants underwent polysomnography and were classified into OSA (apnoea-hypopnoea index (AHI) > 2 per hour) and non-OSA (AHI ≤ 2) groups. Intelligence, memory and learning, academic achievement, behaviour and executive functioning were assessed using the Wechsler Abbreviated Scale of Intelligence, Wide Range Assessment of Memory and Learning 2, Wechsler Individual Achievement Test II (WIAT-II), Behavioural Assessment System for Children 2 and Behaviour Rating Inventory of Executive Function, respectively. RESULTS: Forty-eight per cent (15/31) were classified as having OSA, and 52% (16/31) as non-OSA. The obese cohort performed below the average of normative data on several neurobehavioural measures. WIAT-II maths scores were significantly lower (P = 0.034) in the OSA group than in the non-OSA group (means 84.5 vs. 94.6, respectively), losing significance after adjustment for IQ, age and gender. Self-reported school problems were significantly worse in the OSA group before and after multivariate adjustment (P = 0.010, Cohen's d = 1.02). No other significant differences were found. CONCLUSIONS: Results suggest that OSA may increase risk for some poorer educational and behavioural outcomes. The findings are reasonably consistent with and add to the evidence base of the few studies that have explored this relationship.

Cervical fascia: a terminological pain in the neck.

Although understanding the cervical fascia and its arrangement is an important part of anatomical, surgical and radiological training, it is inconsistently described in textbooks, which makes its study challenging and interdisciplinary communication confusing. This review examines the recommended textbooks for trainees of these disciplines in order to identify areas of agreement and controversy. Not only were the terms used variably between texts, but also key aspects of the anatomical descriptions associated with similar terms differed, contributing further to the confusion.

The effect of a postoperative course of oral prednisone on postoperative morbidity following childhood tonsillectomy.

OBJECTIVE: Tonsillectomy is a common procedure with a wide range of described operative techniques and usage of perioperative medications. Single-dose intraoperative dexamethasone has been shown to decrease postoperative nausea and pain and improve return to normal diet. The aim was to determine if a course of oral postoperative steroids would further decrease postoperative morbidity following tonsillectomy in children. STUDY DESIGN: Randomized, placebo-controlled, double-blinded trial. Power analysis recommended 198 participants. SETTING: A university hospital and private hospital. SUBJECTS AND METHODS: The authors compared a 5-day course of oral prednisolone with placebo in a pediatric population (3-16 years) undergoing tonsillectomy to assess effects on postoperative pain, nausea, and vomiting and return to normal function. They also assessed the effect of corticosteroids on sleep duration and aspects of sleep quality. RESULTS: The results showed no significant difference between the 2 groups when analyzed for differences in the above variables both overall and at each of the postoperative 10 time points (pain, P = .478; nausea and vomiting, P = .556; return to normal diet well, P = .234; return to normal activity, P = .668; bedtime, P = .056; number of times awake during the night, P = .593). CONCLUSION: There is no evidence of benefit from postoperative administration of corticosteroids in pediatric patients recovering from tonsillectomy.

Pulse transit time and assessment of childhood sleep disordered breathing.

OBJECTIVES: To compare nocturnal polysomnography (PSG) with pulse transit time (PTT) recordings and structured clinical assessments and assess the reliability of these methods as a surrogate for the apnea-hypopnea index (AHI; calculated as the number of apneas/hypopneas per hour of total sleep time) and to test the associations between the clinical assessments and sleep disordered breathing (SDB). DESIGN: Prospective observational study. The parents of 51 children and adolescents filled out a questionnaire on SDB and the participants underwent examination. Scores from questionnaire and examination items were weighted according to their association with SDB. A total clinical score was assigned combining questionnaire and examination scores. SETTING: Hospital pediatrics department. PATIENTS: Children and adolescents aged 5 to 17 years undergoing standard PSG with the addition of PTT as part of a clinical investigation for SDB. MAIN OUTCOME MEASURES: The AHI and associations between the AHI and PTT arousal index (PTT-AI) and questionnaire, examination, and total clinical scores. RESULTS: We found a significant correlation between the AHI and PTT-AI (r = 0.55; P < .001). The relationship between the AHI and PTT-AI was stronger when the AHI was greater than 3. We also found significant correlations between the PTT-AI and the total clinical score (r = 0.38; P = .008) and the examination score (r = 0.44; P = .002) but not the questionnaire score (r = 0.23; P = .12). There was an association between the AHI and examination score in particular when the AHI was greater than 3. CONCLUSIONS: Pulse transit time shows promise as a screening test for SDB associated with an AHI greater than 3. For less severe SDB, the validity of using the PTT to separate these conditions from primary snoring has not been demonstrated in a clinical setting.

Surgical anatomy of the chorda tympani: a micro-CT study.

PURPOSE: Iatrogenic injury of the chorda tympani is a well-known complication of middle ear surgery, yet few studies have investigated the intraosseous course of the nerve. The aim of this study was to accurately delineate the posterior canaliculus in the temporal bone, particularly its relationship to the tympanic annulus, which is critical during the insertion of subannular ventilation tubes. METHODS: Forty temporal bones from 27 cadavers (15 male, mean age 75 years, 13 bilateral) were scanned using a micro-CT scanner, and standardised 3-D multiplanar reconstructions were generated using a software platform. The posterior canaliculus was measured in relation to reproducible bony landmarks. RESULTS: In 6 (15%) specimens, the chorda tympani originated from the facial nerve outside the skull and in 34 (85%) from within the facial canal at a mean of 3.2 ± 1.8 mm above the stylomastoid foramen. The posterior canaliculus was 12.3 ± 3.8 mm long and converged on the tympanic sulcus cranially. It entered the middle ear at 62 ± 10% of the height of the tympanic membrane. CONCLUSIONS: This novel micro-CT study defines the precise anatomy of the posterior canaliculus housing the chorda tympani and provides data that may help the otologic surgeon protect the nerve from iatrogenic injury.

Yeast colonization of voice prostheses: pilot study investigating effect of a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies on yeast colonization and valve leakage.

OBJECTIVES: Our goals were to determine whether a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies ("immune milk") could reduce the adherence of C albicans to voice prosthesis silicone in vitro, and whether administration of the milk could reduce C albicans colonization and voice prosthesis damage in vivo. METHODS: An in vitro assay of C albicans attachment to silicone was developed with radiolabeled C albicans. A pilot crossover in vivo trial, over 3 periods of 3 months, was also undertaken for 4 patients with voice prostheses, comparing daily administrations of immune milk and a control milk product. The prosthesis valves were replaced at each changeover and were assessed for wet weight of removable biofilm, yeast numbers in removable biofilm, valve leakage, and valve damage. RESULTS: Immune milk inhibited C albicans adherence to silicone in vitro. However, in a small clinical pilot study, this effect was not replicated. CONCLUSIONS: There is scope to further investigate the topical use of immune milk for management of voice prosthesis biofilms.