CHAPTER 24: Otolaryngology

ADENOTONSILLAR HYPERTROPHY

Enlargement of palatine tonsils and adenoid lymphoid tissue that contributes to obstruction of the upper airway

• Results in sleep disordered breathing defined as an abnormal respiratory pattern during sleep including snoring, mouth breathing, and pauses in breathing which may be symptoms of obstructive sleep apnea (OSA)

EPIDEMIOLOGY

• Volume of lymphoid tissue increases from 6 months of age to puberty; peak of OSA in preschool years, when tissue makes up greatest proportion of upper airway

• Associated craniofacial and neuromuscular disorders and obesity increase likelihood of symptomatic adenotonsillar hypertrophy

PATHOPHYSIOLOGY

• The underlying etiology of adenotonsillar hypertrophy is unknown

• Upper airway obstruction is multifactorial; includes hypertrophied lymphoid tissue, compliance and elasticity of pharyngeal soft tissue, facial morphology, and changes to the pharyngeal musculature during sleep

• Cyclic airway obstruction during sleep causes hypoxia and hypercapnia, leading to arousals to restore respiration

• Repeated arousals interrupt rapid eye movement sleep, which can lead to daytime somnolence

CLINICAL MANIFESTATIONS

• Nighttime: Snoring, apnea, restless sleep, enuresis, nightmares

• Daytime: Somnolence, behavioral changes, learning difficulties, nasal obstruction, mouth breathing, hyponasal speech; in severe cases, dysphagia, failure to thrive

• Degree of tonsillar enlargement: Tonsil within fossa = 0; less than 25% obstruction = 1+; less than 50% obstruction = 2+; less than 75% obstruction = 3+; greater than 75% obstruction = 4+ (Brodsky grading scale) (Figure 24-1)

DIAGNOSTICS

• Overnight polysomnography is definitive test for OSA

• Lateral neck radiograph versus flexible nasopharyngolaryngoscopy (NPL) to assess adenoid size and airway caliber; however, volume of tonsils and adenoids do not always correlate well with severity of OSA

• ECG and/or echocardiogram in severe, longstanding OSA to rule out cor pulmonale—Right heart strain, right ventricular hypertrophy

MANAGEMENT

Medical

• Nasal corticosteroids decrease nasal turbinate and adenoid hypertrophy, and may decrease severity of OSA, improve snoring, and improve nighttime symptoms such an enuresis, though long-term effectiveness unclear. Dosage—1 spray each nostril daily (if under 2 years give every other day)

• Noninvasive positive pressure ventilation (e.g., continuous positive airway pressure)

• Weight loss for obese patients

Surgical

• Indications for adenotonsillectomy

  • ✓ Sleep disordered breathing leading to daytime and nighttime symptoms, and all children with documented OSA

  • ✓ Nasal obstruction causing discomfort in breathing and distortion of speech, or recurrent otitis media (adenoidectomy only)

  • ✓ Dysphagia or speech disturbance (dysarthria or hypernasality) due to large tonsils (tonsillectomy only)

  • ✓ Chronic tonsillitis: 7 episodes in the past year or 5 episodes per ...