Adenotonsillectomy affecting quality of life in pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India

Santosh Kumar Swain; Mahesh Chandra Sahu; Jasashree Choudhury; Nistha Ananda

doi:10.4103/aiao.aiao_29_18

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 1 | Page : 1-4

Adenotonsillectomy affecting quality of life in pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India

Santosh Kumar Swain¹, Mahesh Chandra Sahu², Jasashree Choudhury³, Nistha Ananda¹
¹ Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
² Department of Pediatrics, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
³ Medical Research Laboratories, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission	18-Dec-2018
Date of Acceptance	19-May-2019
Date of Web Publication	27-Jun-2020

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/aiao.aiao_29_18

Abstract

Aim: The aim of this study was to assess the benefits, impact, and efficacy of the adenotonsillectomy (AT) or tonsillectomy or adenoidectomy on quality of life among pediatric patients with chronic tonsillitis or adenotonsillar hypertrophy. Materials and Methods: This was an observational and retrospective study done among children who had undergone AT, tonsillectomy, and adenoidectomy between the ages of 3 years and 16 years during December 2015 to November 2018. Patients were asked by questionnaire for comparing the symptoms before and after 3 months of surgery. Results: There were 220 children who had undergone AT, tonsillectomy, and adenoidectomy. There were 122 male and 98 female children. The age of the children ranged from 3 to 16 years. The mean age of the children was 6.8 years. The mean duration of the clinical symptoms was 2.8 years. The mean attacks of tonsillitis per year, absent days from school, frequency of doctor visits were reduced postoperatively. There was a significant increase in quality of life after AT or tonsillectomy, which was confirmed by statistically validation (P < 0.005) in Student's t-test. Conclusion: AT, tonsillectomy, and adenoidectomy are commonly performed surgical procedures among pediatric patients. All the surgeries are considered as elective procedure often performed in day-care unit where children come by ambulatory, operated, and discharged on the same day of the surgery except if any complications.

Keywords: Adenotonsillar hypertrophy, pediatric patients, quality of life, tonsillectomy

How to cite this article:
Swain SK, Sahu MC, Choudhury J, Ananda N. Adenotonsillectomy affecting quality of life in pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:1-4

How to cite this URL:
Swain SK, Sahu MC, Choudhury J, Ananda N. Adenotonsillectomy affecting quality of life in pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2023 Mar 26];4:1-4. Available from: https://www.aiaohns.in/text.asp?2020/4/1/1/288174

Introduction

Adenotonsillectomy (AT), tonsillectomy, and adenoidectomy are commonly performed surgical procedures among children. All the surgeries are considered as elective procedure often performed in day-care unit where children come by ambulatory, operated, and discharged on the same day of the surgery except if any complications. The need for the benefit of these surgeries has been source of controversy in the medical literature since several decades. Nonetheless, these surgical procedures are definitely beneficial to the patients. The indications for these surgeries are constantly debated in the medical literature. Recurrent throat pain due to chronic tonsillitis, mouth breathing, or sleep apnea is common indications for AT or tonsillectomy or adenoidectomy. Recurrent infections of tonsils and hypertrophy of the palatine tonsils and adenoid are common problem seen in the pediatric age group.^[1] Adenoid hypertrophy is often lead to chronic upper airway obstruction among children. The most common risk factor leading to childhood obstructive sleep apnea syndrome (OSAS) is a chronic adenotonsillar hypertrophy. Recurrent tonsillitis is also an important cause of throat pain in the pediatric age, which affects the quality time in the family. Tonsillectomy for chronic or recurrent tonsillitis is significantly useful for decreasing the severity of throat pain and enhances the quality of life among the children. Chronic tonsillitis is an appropriate term for describing sore throat for at least 3 months along with inflammations of the palatine tonsils. AT, adenoidectomy, and tonsillectomy are usually done in pediatric patients older than 3 years.^[2] It is an important need for a contemporary surgical procedure such as AT or tonsillectomy for benefit in the term of health status from this surgical intervention. These surgical procedures are often performed surgery among the pediatric age group, which help for the mental and physical growth of the child. Its indications and complications have been documented in the medical literature, but to the best of our knowledge, there is no such study regarding the quality of life in our region, i.e., the eastern part of India. The aim of this study is to compare the clinical symptoms before and after the AT, tonsillectomy, or adenoidectomy and its impact on the quality of life in pediatric patients.

Materials And Methods

Children between the age group of 3–16 years who had undergone a tonsillectomy, AT, and adenoidectomy for recurrent tonsillitis or adenotonsillar hypertrophy between December 2015 and November 2018 were included in this study. This study is an observational retrospective study. This study was approved by the Institutional Ethical Committee. Inclusion criteria were recurrent palatine tonsillitis (3–4 episodes of tonsillitis in a year) with throat pain or tonsil Grades II, III, and IV [Figure 1] with obstructive symptoms according to Brodsky classification. X-ray of the nasopharynx with a lateral view [Figure 2] showing Grade III–IV and obstructive symptoms were included in this study. Inclusion criteria were 3–4 episodes of tonsillitis in a year. Exclusion criteria were suspected tonsillar malignancy, bleeding disorders, craniofacial anomaly, and immunodeficiency. Exclusion criteria were also included children with abnormal neurological and psychomotor development from birth, syndromic child, children with congenital hearing loss, children with recurrent pharyngitis or pharyngotonsillitis, asymmetric tonsillar hypertrophy, or possible tumors of the tonsils. There were some questionnaires asked to the parents or children for comparing the symptoms 3 months before and after tonsillectomy, AT, or adenoidectomy. The questionnaires were the frequency of tonsillitis, absence from school or work, frequency of visits to the doctor, sleep apnea, and feeling of well-being. Questionnaires were given to 220 children those who had undergone a tonsillectomy, AT, or adenoidectomy 3 months before and 3 months after surgery. All the surgeries were done by senior surgeons with the help of the coblation technique.

Figure 1: Child with Grade-III tonsils

Click here to view

Figure 2: X-ray of the nasopharynx with a lateral view showing Grade-IV adenoid

Click here to view

Results

All 220 children were enrolled in this study. The age of the children ranged from 3 to 16 years. There were 122 boys and 98 girls. The mean age of the children in the study was 6.8 years. The mean duration of the clinical symptoms was 2.8 years. There were 102 children who had undergone tonsillectomy, 82 AT, and 36 adenoidectomy [Table 1]. None of the 220 children had contraindications to the surgery except five children sent for pulmonary clearance but cleared for the surgery. By reviewing the 220 children, absentees from school due to recurrent sore throat decreased from a mean of 8.50 to 0.58 days per year. Doctor visits (visits per year) reduced from 5.10 to 0.32 postoperatively and >90% showed feelings of well-being. There were children with Grade-III and IV adenoid hypertrophy and Grade-II, III, and IV hypertrophied tonsils present [Table 2]. Airway obstruction with sleep apnea was improved after surgery with good quality of sleep. There was a significant increase in quality of life after AT or tonsillectomy, which was confirmed by statistically validation (P < 0.005) in Student's t-test [Table 3].

Table 1: Number of children undergone adenotonsillar surgery

Click here to view

Table 2: Degree of adenoid and tonsillar hypertrophy

Click here to view

Table 3: Symptomatic improvement and quality of life after pediatric adenotonsillectomy and tonsillectomy

Click here to view

Discussion

AT, tonsillectomy, or adenoidectomy are commonly performed surgical procedures among the pediatric age group. Their indications are often variable and change from center to center. Its main indications are recurrent or chronic tonsillitis, OSAS, recurrent middle ear infections, orthognathic abnormality, and hearing impairment. All these have significant impact on the quality of life for children and their families.^[3] The craniofacial skeleton of the children grows very quickly. Development of the face occurs up to 60% by the age of 4 years, whereas 90% occurs by the age of 11–12 years.^[4] One study on rhesus monkey revealed that blockage of nasal breathing was done by keeping soft, cone-shaped silicon plugs inside the nares causing mouth breathing leading to changes such as narrowing of dental arches, reduced maxillary arch length, anterior crossbite, maxillary overjet, and more anterior face height.^[5] Airway obstruction due to prolonged nasal blockage at an early age due to adenoids or tonsillar hypertrophy affects facial growth and leads to a narrow upper airway before the age of the puberty. Hence, nasal breathing contributes to facial development and also some contribution by the tongue. Prolonged mouth breathing due to adenotonsillar hypertrophy in early childhood and loss of contribution of the tongue on the palatal growth lead to impairment of facial growth, narrow and high-arched palate, retropositioned mandible, hypertrophied inferior turbinate and elongated face. Hypertrophied palatine tonsils or adenoid is one of the frequent clinical conditions seen among the pediatric age group. Adenotonsillar hypertrophy is the major cause for sleep apnea syndrome among children, which accounts for about 75% of the cases.^[6] AT is the treatment of choice which frequently performed surgery by otorhinolaryngologist.^[7] In the mid-20^th century, tonsillectomy or AT were performed in terms of millions for indications of recurrent sore throat. Although the number is decreased in recent past, it still remains one of the commonly performed surgical procedures among pediatric age groups.^[8] At present, AT is done with increasing frequency of obstructive conditions such as sleep apnea and hearing loss children.^[8] In this study, the apneic episodes reduced from 3.02 to 0.01 per night. If adenotonsillar hypertrophy left untreated, it leads to severe complications in children. The implications of obstructive sleep apnea often lead to hypoxemia and sleep fragmentation. If it is untreated or treated late leads to severe neurocognitive, behavioral and cardiovascular morbidities which may not be reversible after proper treatment.^[9] Delayed treatment is often seen among children in developing or underdeveloped country. Prolonged obstructive sleep apnea is often associated with systemic hypertension, cor pulmonale, left ventricular failure, reduced cognitive skill, behavioral disturbances, and failure to thrive.^[10] Hypertrophy of tonsils and adenoid result in airway obstruction causing orthognathic dysfunction, dental arch abnormalities, chewing, and swallowing difficulties.^[11] Other important abnormalities seen are behavioral abnormalities and poor school performance.^[12] Many authors showed that weight gain of children was seen after surgery as weight loss related to the energy loss during sleeping time, respiratory activity due to nocturnal respiratory acidosis, and hypoxemia.^[13] One study demonstrated the weight gain of the children after AT did not lose weight after 5 months of surgery.^[14] Adenotonsillar hypertrophy is the common etiology for nasal obstruction and mouth breathing during childhood. Chronic nasal block leads to a lack of oxygen to the brain and heart which result in severe illness such as depression, mood swings, daytime sleepiness, aggression, and cardiopulmonary abnormality. These breathing disorders may lead to several clinical changes from sleep apnea with or without cardiopulmonary repercussions to craniofacial developmental abnormalities and poor feeding. Due to all clinical symptoms, the child may suffer from school learning disorders, which often reported from parents of the child. Difficulties in school performance are a common reason for sending the child to clinicians. Despite being intelligent, most often children have learning problems. These can be due to emotional disturbances, family issues, or even diseases. In our study, the absenteeism from school was 8.50/year which reduced to 0.58 after AT. Sleep apnea due to adenotonsillar hypertrophy is now a major concern leading to poor school performance, behavioral abnormalities, and low quality of life.^[15] Poor school performance and low intellectual may lead to sufferings to the child with decrease confidence in his/her potentials, feelings of failure, and affect self-esteem. Hence, it can affect the entire development of the child and also to lives of whole family members. AT or tonsillectomy remains the most common performed surgery in otorhinolaryngology practice. In properly selected pediatric patients, it improves the quality of life by solving obstructive symptoms and recurrent throat pain. One study evaluated the quality of life in children with adenotonsillar hypertrophy and obstructive sleep apnea with using general quality of life instruments and disease-specific instruments.^[16] This study revealed the quality of life among children with obstructive sleep apnea improved after surgery of AT or tonsillectomy. We found statistically significant changes in quality of life after AT, tonsillectomy, and adenoidectomy. Following the surgery, the frequency of throat pain per year is reduced from 7.45 to 1.35 episodes and doctor visits decreased from 5.10 to 0.32 per year. Not only the doctor's visits of the children reduced but also antibiotic intake significantly reduced. In consideration of medical cost, overall economic burden on the family was reduced after surgery. Our study adds to other studies that AT or tonsillectomy during pediatric age is effective with a history of recurrent tonsillitis or upper airway obstructive symptoms. Fear, anxiety, and distress can be minimized preoperatively by strengthening the doctor–patient relationship by proper counseling and explaining the risk and benefits of the AT or tonsillectomy. It is always advisable for healthcare provides for giving proper information to the parents of the children regarding risk and benefits otherwise it will be difficult to repair the postoperative behavior sequel.^[17]

Conclusion

AT, tonsillectomy, and adenoidectomy are commonly performed surgeries in pediatric patients have definite evidence for efficacy in terms of quality of life. Majority of the children showed positive scores after surgical intervention. Most of the patients reported less number of doctor visits and decreased requirement of antibiotics, and hence it revealed improvement in physical and mental health. This study will definitely help for providing data regarding efficacy for pediatric AT, tonsillectomy, and adenoidectomy. There should be a community bases preoperative educational program for verbal description to prevent all the complications due to chronic tonsillitis or adenotonsillar hypertrophy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ersoy B, Yücetürk AV, Taneli F, Urk V, Uyanik BS. Changes in growth pattern, body composition and biochemical markers of growth after adenotonsillectomy in prepubertal children. Int J Pediatr Otorhinolaryngol 2005;69:1175-81.
2.	Alho OP, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: Randomised controlled trial. BMJ 2007;334:939.
3.	Bellussi LM, Marchisio P, Materia E, Passàli FM. Clinical guideline on adenotonsillectomy: The Italian experience. Adv Otorhinolaryngol 2011;72:142-5.
4.	Suri JC, Sen MK, Venkatachalam VP, Bhool S, Sharma R, Elias M. Outcome of adenotonsillectomy for children with sleep apnea. Sleep Med 2015;16:1181-6.
5.	Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod 1981;79:359-72.
6.	Nimubona L, Jokic M, Moreau S, Brouard B, Guillois B, Leacheux C. Obstructive sleep apnea syndrome and hypertrophy tonsillar in the infant. Arch Pédiatr 2000;7:961-4.
7.	McNamara F, Sullivan CE. Treatment of obstructive sleep apnea syndrome in children. Sleep 2000;23 Suppl 4:S142-6.
8.	Garetz SL. Behavior, cognition, and quality of life after adenotonsillectomy for pediatric sleep-disordered breathing: Summary of the literature. Otolaryngol Head Neck Surg 2008;138:S19-26.
9.	Sans Capdevila O, Crabtree VM, Kheirandish-Gozal L, Gozal D. Increased morning brain natriuretic peptide levels in children with nocturnal enuresis and sleep-disordered breathing: A community-based study. Pediatrics 2008;121:e1208-14.
10.	Crabtree VM, Varni JW, Gozal D. Health-related quality of life and depressive symptoms in children with suspected sleep-disordered breathing. Sleep 2004;27:1131-8.
11.	DiFrancesco RC, Junqueira PA, Trezza PM, de Faria ME, Frizzarini R, Zerati FE. Improvement of bruxism after T and A surgery. Int J Pediatr Otorhinolaryngol 2004;68:441-5.
12.	Di Francesco RC, Junqueira PA, Frizzarini R, Zerati FE. Growth weight-training of children after adenotonsillectomy. Rev Bras Otorrinolaringol 2003;69:193-6.
13.	Aydogan M, Toprak D, Hatun S, Yüksel A, Gokalp AS. The effect of recurrent tonsillitis and adenotonsillectomy on growth in childhood. Int J Pediatr Otorhinolaryngol 2007;71:1737-42.
14.	Lobo de Alcântara LJ, Pereira RG, Sprotte Mira JG, Soccol AT, Tholke R, Koerner HN, et al. Adenotonsillectomy impact on children's quality of life. Int Arch Otorhinolaryngol São Paulo 2008;12:172-8.
15.	Ikeda FH, Horta PA, Bruscato WL, Dolci JE. Intellectual and school performance evaluation of children submitted to tonsillectomy and adenotonsillectomy before and after surgery. Braz J Otorhinolaryngol 2012;78:17-23.
16.	Flanary VA. Long-term effect of adenotonsillectomy on quality of life in pediatric patients. Laryngoscope 2003;113:1639-44.
17.	Fukuchi I, Morato MM, Rodrigues RE, Moretti G, Simone Júnior MF, Rapoport PB, et al. Pre and postoperative psychological profile of children submitted to adenoidectomy and/or tonsillectomy. Braz J Otorhinolaryngol 2005;71:521-5.