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International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx

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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl

Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy Altug Cincin a,1, Erdal Sakalli b, * ,1, Eftal Murat Bakirci c , Rafet Dizman d a

Marmara University Medical Faculty, Department of Cardiology, Istanbul, Turkey Safa Private Hospital, Department of Otorhinolaryngology, Istanbul, Turkey c Erzincan University Medical Faculty, Department of Cardiology, Erzincan, Turkey d Yunus Emre State Hospital, Department of Cardiology, Eskisehir, Turkey b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 7 March 2014 Received in revised form 6 May 2014 Accepted 7 May 2014 Available online xxx

Objective: The aim of our study was to investigate subclinical cardiac disturbances in patients with symptoms due to adenotonsillar hypertrophy (ATH) and the impact of adenotonsillectomy (AT) using conventional and novel echocardiographic measures. Material and methods: Thirty patients with grade 3 or 4 ATH (mean age: 7.86  3.83 years; 10 females) and 30 healthy, age- and sex-matched volunteers (mean age, 8  2.77; 14 females) were enrolled in the study. In addition to conventional two-dimensional and Doppler echocardiographic parameters, tissue Doppler parameters, including myocardial performance indices (MPIs) of both the right (RV) and left ventricle (LV), were studied. The severity of obstructive sleep apnea (OSA) was determined using the OSA-18 health quality questionnaire. The OSA-18 questionnaire and echocardiographic examination were repeated after AT in patients with ATH. Results: The total OSA-18 scores for the control, preoperative, and postoperative groups were 39.56  19.98, 80.63  22.32, and 44.10  20.31, respectively. Conventional parameters were not different among the groups. The mean pulmonary artery pressure estimated using the Mahan formula was increased in the ATH group compared with that in the control group (21.72  4.25 vs. 12.43  3.83, respectively; p < 0.001) and significantly improved after AT (21.72  4.25 vs. 16.09  4.53; p < 0.001). The RV MPI was significantly different between the control and ATH groups (0.322  0.052 vs. 0.383  0.079, respectively; p = 0.001). Both the LV and RV MPI significantly improved (0.515  0.066 vs. 0.434  0.052, p < 0.001; and 0.383  0.079 vs. 0.316  0.058, p = 0.018, respectively) after surgery for ATH. Conclusions: Our study revealed that the patients with OSA-specific symptoms due to ATH had higher pulmonary artery pressure and impaired RV function according to novel echocardiographic parameters. Surgery for ATH seems to have an important effect on both LV and RV function. ã 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Obstructive sleep apnea Adenotonsillectomy Cardiac function Sleep Echocardiography

1. Introduction The prevalence of obstructive sleep apnea (OSA) is 2–3% in children, and the most common cause of the disease is upper respiratory tract obstruction due to adenotonsillar hypertrophy (ATH) [1]. Adenotonsillectomy (AT) is known to provide symptomatic benefit in children with symptomatic ATH who do not respond to medical treatment [2]. Polysomnography is the gold-

* Corresponding author at: Fevzi cakmak mah, Sisecam bloklari, Emek apt D: 8, Bagcilar, Istanbul, Turkey. Tel.: +90 533 4417710. E-mail address: [email protected] (E. Sakalli). 1 Contributed equally and should be considered aequo loco.

standard test in decision for AT due to OSA, but its applicability in the pediatric age group is low. Alternative methods, including validated questionnaires, physical examination of the palatine and pharyngeal tonsils, and lateral cervical graphy are more frequently used in decision for AT [3,4]. In many studies that included adults, hypoxia, hypercapnia, and pulmonary vasoconstriction, which occur in OSA patients, have been shown to affect cardiopulmonary function negatively [5]. However, evidence-based information in this area is much more limited in children. Some publications have reported that systemic hypertension, growth failure, cor pulmonale, and even death may develop in children with OSA [6,7]. Echocardiography is an easily accessible and noninvasive test with high reproducibility that provides an evaluation of systolic and

http://dx.doi.org/10.1016/j.ijporl.2014.05.011 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: A. Cincin, et al., Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j. ijporl.2014.05.011

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diastolic cardiac function using two-dimensional (2D), Doppler and color Doppler techniques. Tissue Doppler imaging (TDI) is a relatively new method that allows quantitative demonstration of even subclinical functional changes in addition to conventional echocardiographic techniques [8]. Information about systolic or diastolic functions can be obtained by recording the movements of myocardial tissue in the direction of ultrasonic waves in a sample range determined selectively [9]. The myocardial performance index (MPI) is an echocardiographic parameter reflects both systolic and diastolic physiology, and thus, serves as a measure of the global ventricle function. In many previous invasive and non-invasive, a significant correlation of MPI with ventricular function has been shown [10,11]. In a limited number of studies in which MPI measurements in children with OSA were evaluated, increases in the dimensions of the right ventricle (RV) and in pulmonary artery pressure (PAP) were reported to be correlated with global dysfunction in both the RV and left ventricle (LV) [12–14]. The aim of our study was to evaluate cardiopulmonary function and symptom intensity before and after surgery in children with OSA-specific symptoms due to ATH.

the nasal cavity and sizes of the adenoids were evaluated using a flexible nasopharyngoscope. The severity of tonsillary hypertrophy was determined using the Brodsky scale, which is estimated using the ratio of the tonsillary size to the tonsillary support [15]. Evaluation of the pharyngeal tonsils was based on the grade of airway obstruction (Table 1). Subjects with grades 1 and 2 hypertrophy according to the Brodsky scale or airway obstruction were excluded from the study, and those with grades 3 and 4 hypertrophy were included in the study. 4. Quality of life questionnaire The OSA-18 questionnaire, which was developed by Franco et al. [16], was used to evaluate the impact of the disease. The form of quastionnaire was completed by the families of all children in the control and study groups at the beginning of the study and by the families of the children in the study group at the postoperative sixth month. The responsible nurse explained the form to illiterate families in an understandable way. 5. Echocardiography

2. Patients and methods Our study was conducted in the otolaryngology and cardiology clinics of Bayburt Government Hospital, which is the sole tertiary hospital serving in Bayburt city with a capacity of 250-beds. The duration of the study was 12 months. Forty-eight consecutive children with OSA-specific symptoms due to ATH who were referred to the outpatient clinic of the otolaryngology department and planned for AT were evaluated for enrollment. Children who were younger than 2 years or older than 14 years and those who had a body mass index (BMI) >30 kg/m2, known congenital or acquired heart disease, a chronic disease that could explain the OSA-specific symptoms (neuromuscular disorders, genetic syndromes with craniofacial abnormalities), or an additional anatomic anomaly in the upper respiratory tract (deviated septum, nasal polyposis, turbinate hypertrophy) were not included in the present study. A total of 18 patients, including 5 patients under the age of 2 years old, 5 patients with a BMI >30 kg/m2, 3 patients with septal deviation, 3 patients with turbinate hypertrophy, 1 patient with nasal polyposis and 1 patient with craniofacial abnormality were excluded from the study group; thus, 30 subjects were included in the final analyses. Additionally, 30 healthy children were included in the control group. Control subjects were selected within former patients of otolaryngology department and all had been approved as healthy before invited to be a volunteer. The necessary approval for the study was obtained previously from the Erzurum Atatürk University ethics committee. Written informed consent was obtained from the families of all of the subjects. The recommendation for AT was made based on the complaints described by the parents (e.g., snoring, irregular breathing, and irritable sleep) and physical examination findings (obstructive hypertrophy in the palatine and pharyngeal tonsils). Basal demographic information and physical examination findings of all of the patients and controls were recorded. Subject parents were asked to complete a questionnaire (OSA-18) to assess the quality of life of the OSA patients. Echocardiography was performed in all of the patients and controls at baseline. Echocardiography and the OSA-18 were repeated in the sixth month after surgery. Cold-knife tonsillectomy under general anesthesia was the standard surgical technique used in all of the patients. 3. Evaluation of the palatine and pharyngeal tonsils Complete otolaryngoscopic examination and lateral cervical graphy were obtained in all of the subjects. In appropriate cases,

All patients underwent a complete echocardiographic study with a commercially available device by a single and experienced cardiologist who was unaware of patient clinic. Preoperative echocardiographic evaluation of the patients was performed 48 h before surgery, and postoperative evaluation was performed 6 months after surgery. All 2D, M-mode, Doppler, and tissue Doppler measurements were performed with the child in the supine position and during expiration in accordance with the related guidelines [17]. All results were obtained using an average of three consecutive measurements. The mean pulmonary artery pressure (mPAP) was calculated from the pulmonary acceleration time using the Mahan formula [18,19]. Tissue Doppler measurements were obtained by placing the 3.5-mm sample volume to the lateral part of the tricuspid and mitral annulus on the apical four-chamber images. Images were obtained using a Nyquist limit between 20 cm/s and 20 cm/s and >150 squares/s. The peak velocities of early (E') and late (A') diastolic and systolic (S) myocardial motion were recorded. MPIs for each ventricle were then calculated using the recorded isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), and ejection time (ET) [20]. 6. Statistics Continuous variables used in the study were evaluated using the Kolmogorov–Smirnov test, and normally distributed variables are presented as the mean  standard deviation. Variables that were not normally distributed are presented as median (range). To evaluate difference between the groups, Student's t-test was used

Table 1 Tonsillary and pharyngeal hypertrophy scale used in physical examination. Grade

Palatine tonsil examination findings

1

3 4

Tonsils in the tonsillar fossa and barely visible behind the anterior pillars Tonsils in the tonsillar fossa and easily visible behind the anterior pillars Tonsils extended three quarters of the way to the midline Complete obstruction of the airway by enlarged tonsils

Grade 1 2 3 4

Grade of airway obstruction due to pharyngeal hypertrophy 75%

2

Please cite this article in press as: A. Cincin, et al., Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j. ijporl.2014.05.011

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for the variables that were distributed normally, and the Mann– Whitney U-test was used for variables that were not normally distributed. Fisher's exact chi-squared test was used for categorical data. Spearman's test was used in correlation analyses. A p-value

Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy.

The aim of our study was to investigate subclinical cardiac disturbances in patients with symptoms due to adenotonsillar hypertrophy (ATH) and the imp...
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