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Figure 1.
Obstructive Sleep Apnea (OSA)-18 mean scores before and after surgery for domains and items.

Obstructive Sleep Apnea (OSA)-18 mean scores before and after surgery for domains and items.

Figure 2.
Scatterplot of first Obstructive Sleep Apnea (OSA)-18 total scores vs respiratory distress index (RDI).

Scatterplot of first Obstructive Sleep Apnea (OSA)-18 total scores vs respiratory distress index (RDI).

Table 1. 
Obstructive Sleep Apnea–18 Survey Domains and Items
Obstructive Sleep Apnea–18 Survey Domains and Items
Table 2. 
Patient Demographics and Polysomnography
Patient Demographics and Polysomnography
Table 3. 
OSA-18 Mean Scores Before and After Surgery
OSA-18 Mean Scores Before and After Surgery
Table 4. 
Change in OSA-18 Total Score After Adenotonsillectomy
Change in OSA-18 Total Score After Adenotonsillectomy
1.
Hall  MLawrence  L Ambulatory Surgery in the United States, 1996.  Hyattsville, Md: National Center for Health Statistics; 1998. Advance Data From Vital and Health Statistics, No. 300.
2.
Rosenfeld  RGreen  R Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol.1990;99:187-191.
PubMed
3.
American Thoracic Society Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med.1996;153:866-878.
PubMed
4.
Ali  NPitson  DStradling  J Snoring, sleep disturbance, and behaviour in 4-5 year olds. Arch Dis Child.1993;68:360-366.
PubMed
5.
Guilleminault  CPelayo  R Sleep-disordered breathing in children. Ann Med.1998;30:350-356.
PubMed
6.
Guilleminault  CKhramtsov  A Upper airway resistance syndrome in children: a clinical review. Sem Pediatr Neurol.2001;8:207-215.
PubMed
7.
Hunt  CBrouillette  R Abnormalities of breathing control and airway maintenance in infants and children as a cause of cor pulmonale. Pediatr Cardiol.1982;3:249-256.
PubMed
8.
Leach  JOlson  JHermann  JManning  S Polysomnographic and clinical findings in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg.1992;118:741-744.
PubMed
9.
Schechter  MSSection on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics [serial online].2002;109:e69.
PubMed
10.
Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002;109:704-711.
PubMed
11.
Stradling  JThomas  GWarley  AWilliams  PFreeland  A Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet.1990;335:249-253.
PubMed
12.
Suen  JArnold  JBrooks  L Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg.1995;121:525-530.
PubMed
13.
Goldstein  NFatima  MCampbell  TRosenfeld  R Child behavior and quality of life before and after tonsillectomy and adenoidectomy. Arch Otolaryngol Head Neck Surg.2002;128:770-775.
PubMed
14.
Franco  RRosenfeld  RRao  M Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg.2000;123:9-16.
PubMed
15.
Carroll  JLoughlin  G Diagnostic criteria for obstructive sleep apnea syndrome in children. Pediatr Pulmonol.1992;14:71-74.
PubMed
16.
Gozal  D Sleep-disordered breathing and school performance in children. Pediatrics.1998;102:616-620.
PubMed
17.
Achenbach  T Manual for the Child Behavior Checklist/2-3 and 1992 Profile.  Burlington: Dept of Psychiatry, University of Vermont; 1992.
Original Article
February 2004

Quality of Life After Adenotonsillectomy for Obstructive Sleep Apnea in Children

Author Affiliations

From the Departments of Pediatrics (Dr Mitchell) and Surgery (Drs Mitchell and Kelly and Mss Call and Yao), University of New Mexico, Health Sciences Center, Albuquerque. The authors have no relevant financial interest in this article.

Arch Otolaryngol Head Neck Surg. 2004;130(2):190-194. doi:10.1001/archotol.130.2.190
Abstract

Objective  To study changes in quality of life in children after adenotonsillectomy for obstructive sleep apnea (OSA) documented by full-night polysomnography.

Design and Setting  Prospective study of children with OSA at the University of New Mexico Children's Hospital, Albuquerque.

Methods  Caregivers for children were asked to complete the OSA-18 quality of life survey prior to polysomnography. Children who met inclusion criteria and had a respiratory distress index higher than 1 were enrolled in the study and underwent adenotonsillectomy. Caregivers completed a second OSA-18 survey within 6 months of surgery. Scores from the preoperative and postoperative surveys were compared using the paired t test.

Results  The study population included 60 children (mean age, 7.1 [range, 3-12] years), of whom 43 (72%) were male and 30 (50%) were younger than 6 years. Forty-seven children (78%) had a respiratory distress index of 10 or higher. The mean interval between the 2 surveys was 126 days. The mean total OSA-18 score was 71.4 before surgery and 35.8 after surgery. The domain with the greatest change in mean score was sleep disturbance, which improved by 11.5. The changes in total score, in the scores for each domain, and for each item of the OSA-18 survey were highly significant (P<.002).

Conclusions  Children without significant comorbidities show a marked improvement in the domains of sleep disturbance, physical symptoms, emotional symptoms, and daytime functioning as reported by their caregivers after adenotonsillectomy for OSA.

ADENOTONSILLECTOMY, A common surgical procedure, has traditionally been used for the relief of recurrent adenotonsillitis in children. Approximately 274 000 adenotonsillectomies were performed in the United States during 1996,1 but the actual number of tonsillectomies may be higher, since the available statistics are based on data for ambulatory surgery alone. During the past decade, adenotonsillectomy has been used with increasing frequency to treat obstructive sleep apnea (OSA),2 which is a disorder of breathing during sleep characterized by periodic obstruction of the upper airway that interferes with normal respiratory gas exchange and disturbs sleep.3 The estimated prevalence of OSA in 4-year-old children is 1% to 3%.4

Sleep disturbance is children is a spectrum of disorders ranging from primary snoring through upper airway resistance syndrome to OSA.5,6 Children with primary snoring have normal polysomnograms with no evidence of changes in alveolar ventilation or sleep architecture.5 Upper airway resistance syndrome is characterized by polysomnograms that show increased respiratory effort and sleep fragmentation without episodes of hypopnea or apnea.6 Obstructive sleep apnea is characterized by intermittent upper airway obstruction evidenced by hypopnea or apnea that disrupts normal ventilation and sleep patterns.5,6 Obstructive sleep apnea is a more severe disorder that may cause cardiorespiratory complications if left untreated.7 It is possible to distinguish OSA from other types of sleep disordered breathing by documenting hypopnea or apnea during full-night polysomnography.8,9 However, polysomnography is expensive and time-consuming, and facilities for the procedure are not available in all institutions.10 Consequently, only a few previous studies of the outcome of surgical therapy for sleep-disordered breathing have attempted to distinguish OSA from other less severe sleep disturbances.11,12 These studies have shown that most children with OSA who undergo adenotonsillectomy experience resolution of the disorder as documented by postoperative polysomnography.11,12

Even though postoperative polysomnography provides an objective estimate of improvement after surgery, it does not measure reduction in morbidity as perceived by caregivers. Outcomes studies using a validated quality of life instrument administered before and after surgery are necessary to evaluate this change. A previous study of changes in quality of life after adenotonsillectomy did not use polysomnography for the diagnosis of OSA.13 To our knowledge, the present study is the first to examine changes in quality of life in children after adenotonsillectomy for OSA documented by full-night polysomnography.

METHODS

Approval for this study was obtained from the institutional review board of the University of New Mexico School of Medicine, Albuquerque. Children referred to the Pediatric Otolaryngology Service with a sleep disturbance who were shown to have OSA by polysomnography were included in the study. The caregivers of these children were asked to complete an informed consent document before enrolling the children in the study. Exclusion criteria included (1) children younger than 3 years or older than 12 years; (2) children who previously had an adenotonsillectomy or polysomnography; (3) children with craniofacial syndromes, neuromuscular disease, developmental delay, or psychiatric disorders; and (4) children with a respiratory distress index (RDI) lower than 1. A total of 68 children were included in the study.

The effectiveness of adenotonsillectomy for the relief of OSA was evaluated using the OSA-18 quality of life survey.14 The survey (Table 1) comprises 18 items in 5 domains of sleep disturbance, physical suffering, emotional distress, daytime problems, and caregiver concerns. The domains of emotional distress and daytime problems contain 3 items, while the other domains contain 4. A point scale is used, ranging from 1 (none of the time) to 7 (all of the time) to grade the relative severity of the problem addressed in each item. The total score, the domain score, and the item score were recorded. A single quality of life item is also included in the survey. This item asks caregivers to grade their child's quality of life using a visual analog scale ranging from 0 (worse possible quality of life) to 10 (best possible quality of life). The OSA-18 total scores on the first survey were classified as mild (<60); moderate (≥60 to ≤80); or severe (>80).14 A power analysis indicated that a sample size of 60 is adequate to detect a 10-point difference in OSA-18 total score with 80% power and α = .05. Based on the original study by Franco et al,14 a change in OSA-18 total score from 60 to 80 indicates a change from moderate to severe impact on health-related quality of life. Therefore, the present study has more than sufficient power to detect a clinically important change in health-related quality of life based on OSA-18 total score.

All study participants underwent full-night polysomnography15 to document OSA. The following parameters were measured: 4-channel electroencephalography with bilateral central and occipital leads; electro-oculography to measure vertical and horizontal eye movements; electromyography with submental electrodes; electrocardiography; airflow recording through the nose and mouth by a nasal air pressure transducer with end tidal carbon dioxide; thoracic and abdominal effort by piezoelectric sensors; oxygen saturation through pulse oximetry; and tracheal sound recording by using a microphone secured to the neck. Digital videotaping with sound recording was performed throughout the night. A sleep medicine physician interpreted the results of polysomnography. The RDI, defined as the average number of apneas and hypopneas per hour of sleep, was used for diagnosis of OSA, which was identified by an RDI of 1 or higher. Polysomnography findings were classified as mild (RDI <10); moderate (RDI ≥10 to ≤20); or severe (RDI >20).

Caregivers were asked to complete the first OSA-18 survey prior to polysomnography. Children with OSA underwent a monopolar Bovie adenotonsillectomy. Caregivers for these children were asked to complete the OSA-18 survey a second time within 6 months of surgery. The difference score was derived by subtracting the mean postsurgical score from the mean presurgical score. Since a decrease in mean score implies improvement, the mean change is a positive number with the exception of quality of life, where improvement is an increase in score and the mean change for this item is therefore negative. The 95% confidence intervals for difference scores were also calculated. The standardized response mean (SRM), defined as the difference score/SD of the difference score, was used to estimate the extent of improvement after surgery. Scores from the preoperative and postoperative results of the OSA-18 survey were compared using SAS statistical software (SAS Institute Inc, Cary, NC) for the paired t test.

RESULTS

Sixty-eight children were included in the study, of whom 4 were lost to follow-up and 2 did not undergo surgical therapy. The caregivers for 2 children did not complete the postoperative OSA-18 survey. As a consequence, the study population included 60 children. The demographics of these children and the results of polysomnography are presented in Table 2. Of the 60 children, 43 (72%) were male. The mean age of the children at the time of inclusion in the study was 7.1 (range, 3-12) years. Thirty children (50%) were younger than 6 years. The mean RDI was 28, and 47 children (78%) had an RDI of 10 or higher.

The mean interval between the first OSA-18 survey and surgery was 71 days. The mean interval between surgery and the second survey was 55 days. The mean interval between the 2 surveys was 126 (range, 48-275) days.

The results of a t test indicate that there was no significant difference between male and female children in presurgery OSA-18 total scores (P = .40). Similarly, there was no difference based on gender for the postsurgery total scores (P = .21).

The OSA-18 scores before and after adenotonsillectomy for obstructive sleep apnea are presented in Table 3. The total OSA-18 score, the scores for all domains, and all items showed improvement after surgery. The mean total OSA-18 score before surgery was 71.4 and after surgery, 35.8. The mean difference in total score was 35.5 (SRM 1.3). A decrease in OSA-18 total score greater than 20 points was noted in 48 children (80%), and a decrease greater than 10 points was noted in 51 children (85%). The domain with the greatest change in mean score was sleep disturbance, which improved by 11.5 (SRM 1.5). The second greatest mean change was in the domain of caregiver concerns, which improved by 9.0 (SRM 1.2). The smallest mean change was in the domain of emotional distress, which improved by 3.5 (SRM 0.7). The mean score for the quality of life item improved by 1.8 (SRM 0.8).

Among the individual items in the OSA-18 survey, S1 had a mean change of 3.5 (SRM 1.7) after surgery—the largest improvement after surgery. This item (Table 1) asks whether the child had any incidents of loud snoring during the past 4 weeks. Item S2 had a mean change of 2.8 (SRM 1.2) after surgery. This item asks if there have been any incidents of breath holding spells or pauses in breathing at night during the past 4 weeks. The smallest improvement—a change of 0.8—occurred in item P4, which asks if the child has had any difficulty swallowing foods during the last 4 weeks.

The pattern of change in the OSA-18 survey items after surgery is illustrated in Figure 1. The pattern of scores for the individual survey items is remarkably similar before and after surgery, and there is a clear improvement in mean score for each item. For example, item S3, which addresses gasping or choking during sleep, is the lowest scoring item in the sleep disturbance domain both before and after surgery. The total score of the survey and the score for all domains and each of the 18 items showed a significant change after surgery. The results of a paired t test indicate that the changes in each of the domains and items of the OSA-18 survey are highly significant (P<.002).

A scatterplot of the relationship between RDI and the total score on the first OSA-18 survey is shown in Figure 2. The Pearson correlation coefficient for these 2 data sets is 0.20. This indicates the absence of a linear relationship between RDI and the total score on the first survey.

Table 4 gives the change in OSA-18 total score after surgery for groups of children classified either on the basis of the total score on the first OSA-18 survey (group A) or on the basis of RDI (group B). For group A, children with an OSA-18 score higher than 80 showed the most improvement (change ratio, 2.48). Children with a score of 80 or lower but 60 or higher showed an intermediate level of improvement (change ratio, 2.32), and those with a score lower than 60 showed the least improvement (change ratio, 1.39). When the children were classified by RDI (group B), children with an RDI higher than 20 showed the greatest improvement (change ratio, 2.93). However, children with an RDI lower than 10 showed more improvement (change ratio, 2.36) than children with an RDI of 10 or higher but 20 or lower (change ratio, 1.93).

COMMENT

This study confirms that caregivers report an improvement in sleep disturbance, physical suffering, emotional distress, and daytime problems in their children after adenotonsillectomy for OSA. Caregiver's concerns are also reduced. The total score of the survey and the scores for all domains and each of the 18 items showed a significant change after surgery. The domain with the most significant improvement was sleep disturbance. The domain with the least improvement was emotional distress.

Previous studies have shown improvements in the behavior of children who undergo surgical therapy for sleep-disordered breathing. For example, Gozal16 showed a high prevalence of sleep disturbances in a cohort of children who were academically poor achievers and that these children improved academically following surgical therapy to improve the sleep problems. These improvements were not seen in an untreated group of children. Goldstein et al13 showed that behavioral, emotional, and neurocognitive difficulties have a high prevalence in children with sleep-disordered breathing and that these factors improve with surgical therapy. They used the OSA-18 survey14 and the Child Behavior Checklist17 to evaluate changes in behavior and quality of life after adenotonsillectomy in 64 children with sleep-disordered breathing. The child's clinical history and the presence of hypertrophic tonsils and adenoids were used as selection criteria for surgery. Change scores greater than 1.5 were found for the domains of sleep disturbance, caregiver concerns, and physical symptoms after surgery. The results of the present study agree with the results of Goldstein et al13 and confirm that caregivers report a significant improvement in quality of life after their children undergo adenotonsillectomy for a sleep disturbance.

When children were classified on the basis of the initial OSA-18 total score, there was a consistent relationship between the extent of improvement and the severity of the sleep disturbance as reported by the caregivers. When children were classified by RDI, the most severely affected group showed the greatest degree of improvement as well, but the moderately affected group showed the least improvement. This implies that the OSA-18 survey and polysomnography measure different aspects of OSA, which is confirmed by the lack of a significant correlation between RDI and OSA-18 total score.

Polysomnography is used to evaluate a variety of physiological parameters associated with sleep. In contrast, the OSA-18 survey uses a caregiver proxy to evaluate a child's behavior. There are a number of reasons why these 2 methods of evaluation might not generate identical results. For example, caregivers may not observe their child during rapid eye movement sleep and fail to note the peak incidence of apnea and hypopnea, which would be recorded during polysomnography. It is likely that the best approach for estimating improvement in OSA after adenotonsillectomy would be direct evaluation of a child's daytime behavior with psychometric methods in combination with polysomnography to evaluate sleep disturbance.

The present study, to our knowledge, is the first prospective study of improvements in quality of life after adenotonsillectomy in children with OSA proven by polysomnography. This study excluded children with milder forms of sleep disturbance such as primary snoring or upper airway resistance.6 However, this study has a number of limitations. It was not possible to use a control group of children who were diagnosed with OSA but did not undergo adenotonsillectomy. As a consequence, we cannot exclude the possibility that improvement after surgery was due in part to a tendency of the condition to improve with time. In addition, it is not known if the benefits of surgical therapy for OSA last beyond the 6-month follow-up period of this study.

Children with significant comorbidities and children younger than 3 years were excluded from the present study. Therefore, no comment can be made about the outcome of adenotonsillectomy for OSA in these children. Furthermore, since the OSA-18 survey was validated in English, non-English speakers were excluded, and this introduces a further limitation. In addition, almost three quarters of the children included in the study are male. This may be a consequence of the small sample size, but it is conceivable that some aspect of the inclusion process favors male subjects. In spite of these shortcomings, the improvement in OSA-18 scores was dramatic and comprehensive, suggesting that caregivers perceive an unequivocal benefit after adenotonsillectomy for OSA in children older than 3 years who are free of significant comorbidities.

CONCLUSION

Children without significant comorbidities show a marked improvement in the domains of sleep disturbance, physical symptoms, emotional symptoms, and daytime functioning as reported by their caregivers after adenotonsillectomy for OSA.

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Article Information

Corresponding author and reprints: Ron B. Mitchell, MD, Department of Surgery, University of New Mexico, Health Sciences Center, 2211 Lomas Blvd NE, Albuquerque, NM 87131 (e-mail: rmitchell@salud.unm.edu).

Submitted for publication January 8, 2003; final revision received May 23, 2003; accepted June 25, 2003.

References
1.
Hall  MLawrence  L Ambulatory Surgery in the United States, 1996.  Hyattsville, Md: National Center for Health Statistics; 1998. Advance Data From Vital and Health Statistics, No. 300.
2.
Rosenfeld  RGreen  R Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol.1990;99:187-191.
PubMed
3.
American Thoracic Society Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med.1996;153:866-878.
PubMed
4.
Ali  NPitson  DStradling  J Snoring, sleep disturbance, and behaviour in 4-5 year olds. Arch Dis Child.1993;68:360-366.
PubMed
5.
Guilleminault  CPelayo  R Sleep-disordered breathing in children. Ann Med.1998;30:350-356.
PubMed
6.
Guilleminault  CKhramtsov  A Upper airway resistance syndrome in children: a clinical review. Sem Pediatr Neurol.2001;8:207-215.
PubMed
7.
Hunt  CBrouillette  R Abnormalities of breathing control and airway maintenance in infants and children as a cause of cor pulmonale. Pediatr Cardiol.1982;3:249-256.
PubMed
8.
Leach  JOlson  JHermann  JManning  S Polysomnographic and clinical findings in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg.1992;118:741-744.
PubMed
9.
Schechter  MSSection on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics [serial online].2002;109:e69.
PubMed
10.
Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002;109:704-711.
PubMed
11.
Stradling  JThomas  GWarley  AWilliams  PFreeland  A Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet.1990;335:249-253.
PubMed
12.
Suen  JArnold  JBrooks  L Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg.1995;121:525-530.
PubMed
13.
Goldstein  NFatima  MCampbell  TRosenfeld  R Child behavior and quality of life before and after tonsillectomy and adenoidectomy. Arch Otolaryngol Head Neck Surg.2002;128:770-775.
PubMed
14.
Franco  RRosenfeld  RRao  M Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg.2000;123:9-16.
PubMed
15.
Carroll  JLoughlin  G Diagnostic criteria for obstructive sleep apnea syndrome in children. Pediatr Pulmonol.1992;14:71-74.
PubMed
16.
Gozal  D Sleep-disordered breathing and school performance in children. Pediatrics.1998;102:616-620.
PubMed
17.
Achenbach  T Manual for the Child Behavior Checklist/2-3 and 1992 Profile.  Burlington: Dept of Psychiatry, University of Vermont; 1992.
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