Cephalometric analysis of patients with ob- structive sleep apnea (OSA), simple snorers, and normal controls do not show any signifi- cant differences concerning nasal structures [28]. In contrast, Donnelly et al. [110] recently found significantly reduced nasopharyngeal patency and significantly enlarged adenoids in 16 young sleep apneics as compared to 16 age-matched controls. In childhood, ade- noidal hypertrophy is a common feature predisposing to sleep-disordered breathing (SDB). Pediatric OSA is equally common in both sexes [359, 555]. Today, there is evidence that the relative adenoid size strongly corre- lates with the severity of OSA in children [52, 232]. A positive correlation between snoring and adenoid size was described more than 20 years ago [203, 319, 482].
Apart from enlarged adenoids, antral choanal polyps (ACP) may cause snoring or even OSA in children. Only a few cases of chil- dren with snoring as a symptom of ACP have been described [76, 268, 367], and only three well-documented cases of pediatric OSA caused by ACP exist in the literature [46, 426, 440]. Crampette et al. [92] reported on two children with snoring suffering from spheno- choanal polyps.
However, in adults, a complete obstruction of the nasopharynx rarely occurs.
5.1 Effectiveness of Treatment 5.1.1 Corticosteroids
Recently, intranasal corticosteroids have been demonstrated to reduce adenoid size, in- dependent of the individual’s atopic status [360]. In summary, there seems to be evi- dence of an improvement in the severity of OSA in children treated with intranasal corti- costeroids, but further studies are needed before such therapy can be recommended routinely.
5.1.2 Nasopharyngeal Tubes
In 1981, Afzelius et al. [2] reported two pa- tients with severe OSA cured by self-intuba- tion with a nasopharyngeal tube during sleep. The tubes were fitted individually under fiberoptic visualization with a 3.0–
4.0 mm uncuffed latex pediatric endotracheal tube that extended from the nares to a level 5 mm above the epiglottis. No complications were found after 6 months follow-up.
Nahmias et al. [348] treated 44 patients with OSA with nasopharyngeal tubes. At 4 months follow-up, 44 % of the patients still tolerated their tubes. The apnea index (AI) was reduced by 62.3 %. Responder rates were given as 36.4 %, which is higher than the rhi- nosurgical success rates. The reason for this high responder rate might be the splinting of the nasopharynx, which is not affected by rhi- nosurgery.
Masters et al. [315] described the successful use of a modified nasopharyngeal tube to re- lieve upper airway obstruction in nine infants
Nasopharyngeal Surgery 5
with Pierre-Robin sequence, isolated micro- gnathia, Down’s syndrome, and idiopathic generalized hypotension. The well-tolerated tube allows simultaneous use of oxygen prongs. The tube was required for a median of 6 months in children with Pierre-Robin se- quence (n=6) and for up to 15 months for the other infants. Apart from three infants who experienced regurgitation of feeds into the nasopharyngeal tubes in the initial period, no other complication occurred.
5.1.3 Surgical Treatment
Khalifa et al. [258] have reported that en- larged adenoids may be associated with ven- tilatory impairment, which is reversible after adenoidectomy. However, the correlation be- tween adenoid hypertrophy and OSA is not as obvious. Data on the not always sufficient ef- ficacy of isolated adenoidectomy in cases of pediatric OSA have been reported by Niemi- nen et al. [359] in a controlled, prospective, non-randomized clinical trial. Fifty-eight snoring but otherwise healthy children aged 3–10 years with symptoms suggestive of OSA underwent polysomnography twice, namely before and 6 months after surgery. A second group of 30 non-snoring, healthy children served as controls. Twenty-one children with an obstructive apnea hypopnea index (AHI) greater than 2 underwent adenotonsillecto- my. Of the children operated on, 73 % (16/21) had had previous adenoidectomies, which had not resolved the obstructive symptoms, or the symptoms had begun after the ade- noidectomy. The epipharynx was checked in- traoperatively during the adenotonsillecto- my, and none of the children appeared to have substantial re-growth of the adenoidal tissue.
In other words, an isolated adenoidectomy does not seem to be as effective as an isolated tonsillectomy nor as a combined adenoton- sillectomy for OSA. Nevertheless, isolated adenoidectomy has been shown to improve mental performance in children [372].
In the cited cases of antral choanal polyps, OSA resolved after paranasal sinus surgery.
However, this origin of OSA is too rare to rec- ommend paranasal sinus surgery as a stan- dard procedure for OSA.
5.2 Postoperative Care and Complications
This issue will be discussed in context with combined adenotonsillectomies in Sect. 6.1.1.
Apart from the evidence stated there, no re- ports exist of OSA-related problems within the peri- and postoperative period.
For pain control, diclofenac is superior to paracetamol in small children [23]. We also have good first-hand experience with di- clofenac.
5.3 Indications
and Contraindications
As stated in Chap. 6, Sect. 6.1.1, children with severe OSA show reduced neurocognitive per- formance, which is reversible after combined adenotonsillectomy [152]. In the treatment of OSA, adenoidectomy alone is not as effective as combined adenotonsillectomy. Therefore, we prefer and recommend the combined pro- cedure if OSA has been diagnosed. This applies also to children younger than 3 years.
Because the incidence of postoperative com- plications is higher after tonsillectomy in this age group, children under 3 years require more intensive postoperative monitoring.
Less is known about children who snore but do not suffer from severe upper airway obstruction. Recently, two controlled studies indicated that, compared to normal controls, children who snored but were otherwise healthy showed reduced neurocognitive and academic performance [39, 525]. We perform an isolated adenoidectomy in our pediatric patients who do not have any other clinical symptoms of SDB apart from regular snoring.
20 Chapter 5 Nasopharyngeal Surgery
