Tonsillectomy and Adenoidectomy in Children with Sleep-Related Breathing Disorders: Consensus Statement of a UK Multidisciplinary Working Party

Abstract

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a 'concise, accurate and helpful document'. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.

Hot tonsillectomy for paediatric obstructive sleep apnoea

“…Its update in 2009 by Friedman et al 13 showed that although it did not cure most cases of OSA it did improve the apnoea–hypopnoea index. In conclusion, there are lots of literature including level 5 evidence to alert clinicians to the risks to patients’ peritonsillectomy and post-tonsillectomy summarised for instance in Robb et al 's14 Cochrane review. There is however no evidence of the detrimental effects that a delay in treatment can cause patients, especially our higher risk patients who may wait months to years for a bed in a specialist hospital.…”

Paediatric obstructive sleep apnoea

“…13 A UK working party consensus statement endorsed by the British Association of Paediatric Otolaryngology, ENT-UK, the Association of Paediatric Anaesthetists, the Royal College of Anaesthetists, and the Royal College of Paediatrics and Child Health was published in 2009. 25 The statement recognised that in the UK the decision to operate on children with sleep disordered breathing is a clinical one, based on symptom severity.…”

“…As discussed above, adenotonsillectomy is appropriate in some children without further investigations if they have clinical features suggestive of obstructive sleep apnoea. 25 The symptoms and signs need to be considered along with other indications for tonsillectomy and adenoidectomy, such as recurrent tonsillitis or glue ear. Children with fewer symptoms of sleep disorder may still require adenoidectomy or tonsillectomy for other indications.…”

“…Postoperative desaturations can occur in up to 10% of children. 4 25 We thank Mr D Bosman for the clinical photograph.…”

The interpretation of overnight oximetry tracings

“…Guidelines for home oxygen use in children have recently been published 1. The Royal College of Anaesthetists has also produced a consensus statement on adenotonsillectomy in sleep-related breathing disorders 2. However, no guidelines are available for the interpretation of oximetry recordings, therefore making it a potentially subjective test.…”