and Wolfgang Pirsig2
(1)
Department of Otorhinolaryngology Head and Neck Surgery, Asklepios Clinic Harburg, Eissendorfer Pferdeweg 52, 21075, Hamburg, Germany
(2)
Department of Otorhinolaryngology Head and Neck Surgery, Mozartstrasse 22/1, 89075 Ulm, Germany
Abstract
(Adeno)tonsillar hypertrophy and its surgical removal will be discussed in Sect. 6.1.1 in Chap. 6. In children, apart from enlarged adenoids, antral choanal polyps are the main cause for nasopharyngeal obstruction. In adults, case reports describe various tumors of the nasopharynx as the cause of obstructive sleep apnea (OSA). Topical nasal steroids have proven to be helpful in children with enlarged adenoids. Nasopharyngeal tubes are effective as well but are afflicted with minor compliance rates. Surgical removal of adenoids or other nasopharyngeal tumors is the treatment of choice. In adults, complete obstruction of the nasopharynx rarely occurs. The treatment is mainly surgery.
Core Features
In children, apart from enlarged adenoids, antral choanal polyps are the main cause for nasopharyngeal obstruction. In adults, case reports describe various tumors of the nasopharynx as the cause of obstructive sleep apnea (OSA).
Topical nasal steroids have proven to be helpful in children with enlarged adenoids. Nasopharyngeal tubes are effective as well but are afflicted with minor compliance rates. Surgical removal of adenoids or other nasopharyngeal tumors is the treatment of choice.
In adults, complete obstruction of the nasopharynx rarely occurs. The treatment is mainly surgery.
Cephalometric analysis of patients with obstructive sleep apnea (OSA), simple snorers, and normal controls does not show any significant differences concerning nasal structures [42]. In contrast, Donnelly et al. [159] found significantly reduced nasopharyngeal patency and significantly enlarged adenoids in 16 young sleep apneics as compared to 16 age-matched controls. In childhood, adenoidal hypertrophy is a common feature predisposing SDB. Pediatric OSA is equally common in both sexes [507, 799]. Today, there is evidence that the relative adenoid size strongly correlates with the severity of OSA in children [74, 261, 323]. A positive correlation between snoring and adenoid size was already described more than 20 years ago [281, 451, 695].
Apart from enlarged adenoids [836], antral choanal polyps (ACP) may cause snoring or even OSA in children. Only a few cases have been described with snoring of children as a symptom of ACP [103, 374, 528], and only three well-documented cases of pediatric OSA caused by ACP exist in the literature [66, 618, 638]. Crampette et al. [129] reported on two children with snoring suffering from sphenochoanal polyps. Gong et al. [238] described an 11-year-old girl with retropharyngeal lipoma with OSA (AHI = 13.9) and growth reduction (BMI = 16.9 kg/m2). Six months after successful surgery, BMI increased to 18.9 kg/m2 (no postop PSG).
In adults, however, a complete obstruction of the nasopharynx rarely occurs. Piccin and Sorrenti [562] report on a 73-year-old female with OSA (AHI = 43, ESS = 15), obesity (BMI = 32), and nCPAP incompliance. Her retropharyngeal lipoma was operated. After 1 month, all symptoms disappeared (AHI = 12, ESS = 4). They cite three other cases with OSA because of a retropharyngeal lipoma in a 36-year-old man [5], in a 56-year-old man [152], and in a 64-year-old man [285]; all were cured of OSA after tumor removal.
5.1 Effectiveness of Treatment
5.1.1 Corticosteroids
Intranasal corticosteroids have been demonstrated to reduce adenoid size, independent of the individual’s atopic status [77, 510]. To sum it up, there seems to be some evidence of an improvement in the severity of OSA in children treated with intranasal corticosteroids, but further studies are needed before such therapy can be routinely recommended.
5.1.2 Nasopharyngeal Tubes
Already in 1981, Afzelius et al. [2] reported about two patients with severe OSA cured by self-intubation with a nasopharyngeal tube during sleep. The tubes were individually fitted 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. Within 6-months follow-up, no complications were found.
Nahmias and Karetzky [488] treated 44 patients with OSA with nasopharyngeal tubes. At 4-months follow-up, 44% of the patients still tolerated their tubes. The AI was reduced by 62.3%. Responder rates were given as 36.4%, which is higher than the rhinosurgical success rates. The reason for this high responder rate might be the splinting of the nasopharynx, which is not affected by rhinosurgery.
Masters et al. [442] described the successful use of a modified nasopharyngeal tube to relieve upper airway obstruction in nine infants with Pierre-Robin sequence, isolated micrognathia, 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 sequence (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.
5.2 Surgical Treatment
Khalifa et al. [358] have reported that enlarged adenoids may be associated with ventilatory impairment which is reversible after adenoidectomy. However, the correlation between adenoid hypertrophy and OSA is not as obvious. Data on the not-always-sufficient efficacy of isolated adenoidectomy in cases of pediatric OSA have been reported by Nieminen et al. [507] in a controlled, prospective, nonrandomized 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 nonsnoring, healthy children served as controls. Twenty-one children with an obstructive AHI greater than 2 underwent adenotonsillectomy. Seventy-three percent of the children operated on (16/21) had had previous adenoidectomies, which had not resolved the obstructive symptoms, or the symptoms had begun after the adenoidectomy. The epipharynx was checked intraoperatively during the adenotonsillectomy, and none of the children appeared to have substantial regrowth of the adenoidal tissue. In other words, an isolated adenoidectomy does neither seem to be as effective as an isolated tonsillectomy nor as a combined adenotonsillectomy for OSA. Nevertheless, isolated adenoidectomy has been shown to improve mental performance in children [538].
In the cited cases of ACP, OSA resolved after paranasal sinus surgery. However, this origin of OSA is too rare to recommend paranasal sinus surgery as standard procedure for OSA.
5.3 Postoperative Care and Complications
This issue will be discussed in context with combined adenotonsillectomies in Sect. 6.1.1 in Chap. 6. Apart from the evidence stated there, no reports exist of OSA-related problems after isolated adenoidectomy within the peri- and postoperative period. Adenoidectomy is usually performed on an outpatient basis, the documentation of a standardized bleeding history prior to surgery is strongly recommended before adenoidectomy [651]. Most problems occur after adenoidectomy in early life and in obese children [261, 313, 444].
For pain control, diclofenac turned out to be superior to paracetamol in small children [33]. We have good first-hand experience with diclofenac, and with ibuprofen.
5.4 Indications and Contraindications
As stated in Sect. 6.1.1 in Chap. 6, children with severe OSA show reduced neurocognitive performance, which is reversible after combined adenotonsillectomy [209]. In the treatment of OSA, adenoidectomy alone is not as effective as combined adenotonsillectomy. Therefore, we prefer and recommend the combined procedure if OSA has been diagnosed. This applies also to children younger than 3 years, even though the incidence of postoperative complications is higher after tonsillectomy in this age group. This fact means that children under 3 years require more intensive postoperative monitoring.
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