Volume 5, No. 9 September,
2024
p
ISSN 2723-6927-e ISSN 2723-4339
The Analysis
Study of Adenotonsillectomy For Obstructive Sleep
Apnea and Quality Of Life: A Systematic Review
Putri Maura Widyaratri1, kevin krishnadi hermawan2, Nidyasari
Citraningrum Satyarini3*
Universitas Jember, Indonesia1, universitas islam malang, Indonesia2,
universitas islam indonesia3
Email: putrie_maura@yahoo.com, kevinkrishna91@gmail.com, nidyasaricitraningrumsatyarini@gmail.com
ABSTRACT
The recommended course of
therapy for children with obstructive sleep apnea
syndrome (OSAS) is adenotonsillectomy. We wanted to find out if adenoidectomy
alone is a realistic and suitable treatment for kids with OSAS as it may be
linked to much reduced rates of morbidity, death, and expense. This systematic
review is to review the quality of life of adenotonsillectomy in
patients with obstructive sleep apnea. This study demonstrated compliance with all
requirements by means of a comparison with the standards established by the
Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)
2020. Thus, the specialists were able to guarantee that the research was as
current as feasible. Publications released between 2014 and 2024 were
considered for this search strategy. This was accomplished by utilizing a
number of distinct online reference sites, including Pubmed,
ScienceDirect, and SagePub. It was determined that
reviews, previously published works, and partially completed works would not be
included. In the PubMed database, the results of our search brought up 1.446
articles, whereas the results of our search on SCIENCE DIRECT brought up 2.514
articles, our search on SAGEPUB brought up 749 articles. The results of the
search conducted for the last year of 2014 yielded a total 913 articles for
PubMed, 1.321 articles for SCIENCE DIRECT and 749 articles for SAGEPUB. In the
end, we compiled a total of
8 papers, 5 of which came from PubMed, 2 of which came from
SCIENCE DIRECT and 1 of which came from SAGEPUB. We included eight research
that met the criteria. In summary, the
adenotonsillectomy in patients with obstructive sleep apnea has improved in
behavior, symptoms, and quality of life were among
the secondary outcomes.
Keywords: adenotonsillectomy, obstructive, sleep apnea
Introduction
The term "sleep-disordered breathing" (SDB)
refers to a group of conditions that can range from frequent episodes of
obstructed breathing during sleep to persistent snoring. Between 6% and 17% of
kids are affected by the illness, and children from low-income or racially
marginalized families are more likely to be affected. Untreated SDB may result
in behavioral issues, excessive daytime drowsiness,
impaired growth, neurodevelopment, and quality of life, as well as a higher
risk of metabolic and cardiovascular disorders (Thomas et al., 2022).
In the US, 1.2% to 5.7% of children suffer from pediatric obstructive sleep apnea
(OSA). Although adenotonsillectomy (AT) is the recommended first treatment for pediatric OSA, more than 25% of children still experience
persistent OSA following AT (Tauman et al., 2006).
Providing management advice might be challenging
because to the dearth of published research examining the long-term effects of
continuous OSA therapy in children. Research on primary OSA in children
initially diagnosed with mild to moderate OSA and treated with AT has
demonstrated modest behavioral and quality of life
benefits, but there is inconsistent data regarding changes in attention and
neurocognitive function (Venekamp et al., 2015).
The postoperative treatment of children
undergoing AT for primary sleep disordered breathing (SDB) or OSA varies widely
in practice. For these kids, routine clinical follow-up is not always provided,
and when it is, it usually takes place over the phone or online without an
in-person assessment. Furthermore, only few clinical circumstances may warrant
the use of postoperative polysomnography (PSG). In the treatment of kids with
chronic OSA, there is likewise no guideline for the best time to do postoperative
PSG (Manickam et al., 2016).
Research Methods
Protocol
The author of this study ensured that it
complied with the standards by adhering to Preferred Reporting Items for
Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. This is done to
guarantee the accuracy of the results that are derived from the investigation. Thus, the specialists were able to guarantee that the
research was as current as feasible. Publications released between 2014 and
2024 were considered for this search strategy. This was accomplished by
utilizing a number of distinct online reference sites, including Pubmed, ScienceDirect, and SagePub.
It was determined that reviews, previously published works, and partially
completed works would not be included.
Criteria for Eligibility
In order to completse
this literature evaluation, we looked at published research that discusses e
quality of life of adenotonsillectomy in patients with obstructive sleep apnea.
This is done to enhance the patient's therapy management and to offer an
explanation. This paper's primary goal is to demonstrate the applicability of
the issues that have been noted overall.
To be eligible to participate in the study,
researchers had to meet the following requirements: 1) English must be used to
write the paper. The manuscript must fulfill both of these conditions in order
to be considered for publication. 2) A few of the examined studies were
released after 2013 but prior to the time frame considered relevant by this
systematic review. Editorials, submissions without a DOI, already published
review articles, and entries that are nearly exact replicas of journal papers
that have already been published are a few examples of research that are
prohibited.
Search Strategy
We used "adenotonsillectomy”, and
“obstructive sleep apnea” out using
the PubMed, Science
Direct and SAGEPUB databases by inputting
the words: (("adenotonsillectomies"[All Fields] OR
"adenotonsillectomy"[All Fields]) AND ("obstructive sleep
apnoea"[All Fields] OR "sleep apnea, obstructive"[MeSH Terms] OR
("sleep"[All Fields] AND "apnea"[All Fields] AND
"obstructive"[All Fields]) OR "obstructive sleep apnea"[All
Fields] OR ("obstructive"[All Fields] AND "sleep"[All
Fields] AND "apnea"[All Fields]))) AND ((clinicalstudy[Filter] OR
clinicaltrial[Filter] OR controlledclinicaltrial[Filter]) AND
(2014:2024[pdat])) used in searching the literature.
Data retrieval
After reading the abstract and the title of
each study, the writers performed an examination to determine whether or not
the study satisfied the inclusion criteria. The writers then decided which
previous research they wanted to utilise as sources for their article and
selected those studies. After looking at a number of different research, which
all seemed to point to the same trend, this conclusion was drawn. All
submissions need to be written in English and can't have been seen anywhere
else.
Figure 1. Prisma Flow Diagram
Only those papers that were able to satisfy
all of the inclusion criteria were taken into consideration for the systematic
review. This reduces the number of results to only those that are pertinent to
the search. We do not take into consideration the conclusions of any study that
does not satisfy our requirements. After this, the findings of the research
will be analysed in great detail. The following pieces of information were
uncovered as a result of the inquiry that was carried out for the purpose of
this study: names, authors, publication dates, location, study activities, and
parameters.
Quality Assessment and Data
Synthesis
Each author did their own study on the
research that was included in the publication's title and abstract before
making a decision about which publications to explore further. The next step
will be to evaluate all of the articles that are suitable for inclusion in the
review because they match the criteria set forth for that purpose in the
review. After that, we'll determine which articles to include in the review
depending on the findings that we've uncovered. This criteria is utilised in
the process of selecting papers for further assessment. in order to simplify
the process as much as feasible when selecting papers to evaluate. Which
earlier investigations were carried out, and what elements of those studies
made it appropriate to include them in the review, are being discussed here.
Results and Discussion
In the PubMed database, the results of our
search brought up 1.446 articles, whereas the results of our search on SCIENCE
DIRECT brought up 2.514 articles, our search on SAGEPUB brought up 749
articles. The results of the search conducted for the last year of 2014 yielded
a total 913 articles for PubMed, 1.321 articles for SCIENCE DIRECT and 749
articles for SAGEPUB. In the end, we compiled a total of 8 papers, 5 of which came from PubMed,
2 of which came from SCIENCE DIRECT and 1 of which came from SAGEPUB. We
included eight research that met the criteria.
(Redline et al., 2023) showed that when compared to careful waiting, adenotonsillectomy
did not substantially enhance executive function or attention in children with
moderate SDB at one year of age. On a 12-month follow-up, children who received
adenotonsillectomy, however, had better secondary outcomes, such as behavior, symptoms, and quality of life, as well as lower
blood pressure and AHI.
(Garetz et al., 2015) showed that parent-rated general and OSAS-specific
QoL measures and OSAS symptoms improved considerably more after
adenotonsillectomy than during watchful waiting.
(Hartmann et al., 2021) showed that in children with mild OSA, there is a
strong correlation between the frequency of slow, high-amplitude waves and behavioral functioning as well as quality of life. After
around seven months of follow-up, early AT in children with mild-to-moderate
OSA did not change the microstructure of nonrapid eye movement sleep as
compared to watchful waiting.
(Taylor et al., 2016) showed that when children with OSAS were given
cognitive tests without protracted desaturation, small and specific benefits of
AT were seen. In comparison to data from the Childhood Adenotonsillectomy
Trial, which indicates that surgery has greater impacts on quality of life, behavior, and sleep, in may not be as effective in
reversing the cognitive consequences of OSAS, or it may take longer for the
benefits to materialize.
Table 1. The litelature include in this study
|
Author |
Origin |
Method |
Sample |
Result |
|
Redline et al, 2023 |
USA |
Randomized clinical trial |
459 patients |
In terms of executive function (BRIEF
GEC T-scores: −3.1 for adenotonsillectomy vs. −1.9 for watchful
waiting; difference, −0.96 [95% CI, −2.66 to 0.74]) and attention
(GNG d-prime scores: 0.2 for adenotonsillectomy vs. 0.1 for watchful waiting;
difference, 0.05 [95% CI, −0.18 to 0.27]), there were no statistically
significant differences between the 2 groups at 12 months. Adenotonsillectomy
resulted in greater improvements in behavioral
issues, tiredness, symptoms, and quality of life than did watchful waiting.
Less development of the AHI to more than 3 events/h and a larger 12-month
reduction in systolic and diastolic blood pressure percentile levels were
linked to adenotonsillectomy. Adenotonsillectomy-related major adverse events
affected six children (2.7%). |
|
Garetz et al, 2015 |
USA |
Randomized controlled trial |
453 patients |
Children
randomized to receive an adenotonsillectomy showed greater improvements in
the majority of QoL and symptom severity measurements. These measurements
included the Pediatric Quality of Life Inventory,
which was completed by parents (effect size [ES]: 0.37), the 18-item
Obstructive Sleep Apnea QoL instrument (ES: –0.93),
the modified Epworth Sleepiness Scale score (ES: –0.42), and the Pediatric Sleep Questionnaire's Sleep-Related Breathing
Scale (ES: –1.35). Obesity and baseline severity did not alter the effect,
however race did in several symptom assessments. Reductions in the severity
of OSAS were only partially responsible for the observed variations. |
|
Hartmann et al, 2021 |
Multiple country |
Randomzied controlled trial |
179 patients |
Higher A1 phases per sleep hour was
significantly linked to lower quality of life (OSA-18: ρ = 0.27, p =
0.022; PedsQL: ρ = −0.29, p = 0.015) and
worse behavioral functioning (caregiver Behavior Rating Inventory of Executive Function (BRIEF)
Global Executive Composite (GEC): ρ = 0.24, p = 0.042; caregiver
Conners’ Rating Scale Global Index: ρ = 0.25, p = 0.036). This
association did not hold true for the entire sample. Changes in CAP parameters
were similar in the eAT and WWSC arms at the
7-month follow-up. Variations in behavioral,
cognitive, and quality-of-life performance assessments at follow-up were not
significantly explained by CAP changes. |
|
Taylor et al, 2016 |
USA |
Randomized controlled trial |
227 patients |
For
both groups, the mean test results were within the average range. During the
follow-up period, the eAT group's scores improved
more significantly (P <.05) than those of the watchful waiting group.
These changes had tiny effect sizes (Cohen's d, 0.20–0.24) and were only
observed on tests of fine motor abilities, selective attention, and nonverbal
thinking. Improvements in sleep measurements were linked to increases in test
scores for the eAT group, providing more proof of
the impact of AT on scores. |
|
Katz et al, 2014 |
USA |
Randomized controlled trial |
464 patients |
Both the WWSC and eAT
intervention groups showed interval increases in the BMI z score (0.13
vs.0.31), although the effects of eAT were larger
(P <.0001). Once the effects of baseline weight and AHI were taken into
account, statistical modeling revealed that the BMI
z score grew substantially higher in conjunction with eAT.
Over the course of the 7-month period, a higher percentage of overweight
children assigned to eAT than WWSC acquired obesity
(52% vs. 21%; P <.05). The follow-up AHI, race, and gender did not
substantially correlate with the change in BMI z score. |
|
Fehrm et al, 2018 |
Sweden |
Randomized clinical trial |
83 patients |
The mean (SD) preoperative OAHI score was
23.8 (11.8) for APP and 23.8 (11.5) for ATE. Both the APP and ATE groups had
a significant decrease in mean OAHI score after surgery (−21.7; 95% CI,
−26.3 to −17.2; and −21.1; 95% CI, −24.5 to
−17.7, respectively), but there was no significant difference between
the groups (0.7; 95% CI, −4.8 to 6.1). Furthermore, no significant
differences between the groups were seen regarding other polysomnography
variables (eg, respiratory distress index: mean, 0.6; 95% CI, −5.0 to
6.3) or the OSA-18 questionnaire (eg, total symptom score: −0.5; 95%
CI, −13 to 12). One patient from each group was readmitted owing to
postoperative bleeding, but no other complications were seen. |
|
Efune et al, 2024 |
USA |
Prospective cohort study |
60 patients |
Our sample's median (range) age was 4
years (1–16), and 27 (45%) of the participants were female. Among the
youngsters in our cohort, 80% (n = 48) were of the Black and Hispanic races.
Only 21 (35%) experienced clinically evident respiratory events, whereas
thirty-nine (65%) had at least one episode of respiratory depression or
airway blockage in the PACU as determined by the RVM. The following
characteristics were linked by Poisson regression to an increase in episodes
of respiratory depression and airway obstruction: two or more comorbidities
(estimate 1.96; [1.11-3.46]), BMI Z-score 1-2 (estimate 2.04; [1.20-3.48]),
and BMI Z-score less than -1 (estimate 3.91; [95%CI 1.49-10.23]). |
|
Caetta et al, 2021 |
USA |
Prospective cohort study |
560 patients |
There
were fifteen children (2.7% [95% CI 1.3, 4.0]) who experienced a respiratory
problem during or after surgery. Nine patients experienced moderate problems
such as stridor, croupy cough, laryngospasm, and desaturation; these did not
extend the scheduled hospital or ambulatory stay. Based on their age, severe
sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%), or
underlying medical condition, all six of the children with more severe
complications—including prolonged desaturation, tachypnea,
atelectasis, intercostal retraction, and obstructive apnea
requiring continuous positive airway pressure—were planned admissions. 113
(68.5%) of the 165 children age ≥3 who had an AHI ≥10 but <24
and no medical comorbidities that were known to be predictive of
postoperative problems were sent home the same day of surgery without
experiencing any further respiratory sequelae. |
(Katz et al., 2014) showed
that even in children who were already overweight, eAT
for OSAS causes a clinically significant increase in weight gain beyond
expectations. Children who are overweight are more likely to become obese,
which increases their chance of developing OSAS and other negative effects of
obesity. Following eAT for
OSAS, weight monitoring, dietary counseling, and
physical activity promotion should be taken into consideration.
(Fehrm et al., 2018) showed
that in this group of generally healthy children with severe OSA, the
randomized clinical trial did not demonstrate that APP was more beneficial than
ATE in terms of objective PSG variables and OSA-18 scores. According to this
research, ATE should be the mainstay of care for children with severe OSA.
(Efune et al., 2024) showed
that impaired breathing is more commonly detected by respiratory volume
monitoring in the early postoperative phase following juvenile high-risk
adenotonsillectomy than is clinically evident.
(Caetta et al., 2021) showed
that according to this study, there is little chance of respiratory issues
following an adenotonsillectomy. Children who are in good health and whose AHI
is less than 24 years old may be eligible for ambulatory release.
DISCUSSION
Children with obstructive sleep apnea
(OSA) have recurrent upper airway collapses and airflow cessations while they
sleep. Loss of neuromuscular compensation and upper airway constriction are pathopahysiological factors of pediatric
OSA. The primary cause of upper airway obstruction in children is thought to be
hypertrophy of the tonsils and adenoids. As a result, adenotonsillectomy is
frequently regarded as the initial course of treatment for juvenile OSA (Kaditis et al., 2016).
About 1% to 3% of children suffer from obstructive
sleep apnea syndrome (OSAS), which has been linked to
a higher risk of cardiovascular disease and other systemic morbidities.
Children's behavioral problems have been linked to
even milder kinds of sleep-disordered breathing. There is also evidence linking
pediatric OSAS to a decline in health-related quality
of life (QoL). Research (including a recent meta-analysis) showed that kids
with OSAS had similar to kids with juvenile rheumatoid arthritis and poorer
generic health-related QoL ratings than kids in the healthy group. More than
half of the children assessed had moderate to significant impairment of
disease-specific QoL (Garetz et al., 2015).
The AASM defines pediatric
OSA PSG findings of 1 or more obstructive apnea,
mixed apnea, or hypopnea per hour, OR a pattern of
obstructive hypoventilation associated with (1) snoring, (2) flattened
inspiratory nasal pressure waveforms, and/or (3) paradoxical thoracoabdominal
motion. Despite the lack of guidelines, this definition is applicable to
children with persistent or recurrent pediatric OSA (Sateia, 2014).
Over a 12-month period, behavior, symptom
load, quality of life, blood pressure, and AHI level were among the secondary
outcomes that were improved by surgery. According to the latest research,
children who snore regularly may still benefit from surgery even if their
polysomnography AHI is low. The usefulness of the AHI for risk stratification
in children who are usually healthy is called into question by the current
findings and the literature from the past, which also supports the significance
of symptoms as endpoints and predictors of treatment response (Redline et al., 2023).
The results of the large-scale, multisite,
prospective, randomized controlled study by Garetz,
et al, of AT for PSG-documented pediatric OSAS showed
that children treated with surgical AT showed a significant and substantial
improvement in key parent-reported measures of quality of life and symptoms, or
"patient-centered outcomes," compared to
children treated with WWSC. Improvements in PSG indicators of disease severity
were linked to improvements in QoL and OSAS symptoms; however, the PSG
indicators accounted for a very modest fraction of the observed improvements in
QoL and symptoms (Garetz et al., 2015).
Children with moderate OSA (AHI > 10) have a strong
correlation between a greater frequency of slow, high-amplitude rhythms, or
so-called A1 phases, and poorer behavioral
functioning, as well as a lower quality of life as reported by their caregivers
at baseline, according to research by Hartmann et al. In children with mild
OSA, there is a strong correlation between the frequency of slow,
high-amplitude waves and both behavioral functioning
and quality of life. When compared to watchful waiting, early AT has no effect
on the microstructure of NREM sleep in children with mild-to-moderate OSA (Hartmann et al., 2021).
According to study of Taylor et al., children with
OSAS who do not have prolonged desaturation and who have average general
cognitive functioning may benefit somewhat from AT on cognitive test scores.
The findings encourage further investigation into the neurological and
cognitive impacts of AT for pediatric OSAS (Taylor et al., 2016).
When eAT was used for polysomnographically verified juvenile OSAS, a randomized
controlled study by Katz et al. found that weight and BMI z score increased
considerably more after 7 months of AT compared to WWSC. This study implies
that the significant negative effects of OSAS on energy balance and metabolism
are at least partially reversible upon therapy. When eAT
was administered to otherwise healthy 5- to 9.9-year-old children with OSAS,
weight and BMI z scores increased more than when WWSC was used. In particular,
children with FTT, normal weight, and overweight showed increases in the BMI z
score following AT. Interestingly, throughout the course of the trial, 51% of
overweight children who were randomized to eAT
developed obesity (Katz et al., 2014).
One of the risk factors for chronic OSA following
surgery is severe OSA. The findings demonstrated that in terms of change in
mean OAHI score, other respiratory PSG variables, and OSA-18 scores, APP was
not superior than ATE in this research cohort. Out of the 47 patients, only one
had severe OSA that persisted following ATE. According to this research, ATE
should be the mainstay of care for kids with severe OSA (Fehrm et al., 2018).
Conclusion
In summary, the adenotonsillectomy in
patients with obstructive sleep apnea has
improved in behavior, symptoms, and quality of life
were among the secondary outcomes. Future studies are required to provide
simple screening tools that may be used to determine which patients are more
likely to benefit from adenotonsillectomy as opposed to watching and waiting.
Finding objective metrics that more accurately describe the physiological
factors mediating the health consequences is also necessary.
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