Does the tonsillar surface flora differ in children with and without tonsillar disease?

OBJECTIVE: To investigate whether the tonsillar flora differ in children with and without adenotonsillar disease. MATERIAL AND METHODS: Tonsil surface swabs were taken from 218 children indicated for adenotonsillectomy because of moderate symptoms of recurrent tonsillopharyngitis or adenotonsillar hypertrophy (T+Ads group). Control swabs were taken from 100 children without symptoms of adenotonsillar disease who visited the ophthalmology clinic. Potential respiratory pathogens were identified. RESULTS: Potential respiratory pathogens were found in 54% of the T+Ads group, compared to 41% of the control group (p = 0.04). Haemophilus influenzae was the commonest pathogen in both groups, being found in 41% of the T+Ads group and 34% of the control group. Moraxella catarrhalis was found more often in the T+Ads group compared to the control group: 7% vs 0% (p = 0.004). H. influenzae was found in 32% of the children with recurrent tonsillitis, compared to 48% of the children with symptoms of tonsillar hypertrophy (p = 0.03). CONCLUSIONS: The prevalence of potential respiratory pathogens on the tonsillar surface of children with moderate symptoms of recurrent tonsillopharyngitis and/or tonsillar hypertrophy differs only slightly from that in children without symptoms of adenotonsillar disease. Variations in the microbial flora do not seem to play an essential role in the predisposition of these children to tonsillar disease.     

Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3–6 year old children undergoing adenotonsillectomy

IntroductionAdenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3–6 years with caregiver-reported symptoms.MethodsChildren 3–6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.ResultsThe cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = −0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.ConclusionSubjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3–6 years of age undergoing adenotonsillectomy.     

An investigation of the significance of Actinomycosis in tonsil disease

OBJECTIVES: The objective of the study was to establish the incidence of Actinomycosis in the tonsils of children undergoing tonsillectomy or adenotonsillectomy, and to evaluate its role in clinical tonsillar disease. METHODS: This was a prospective controlled study done at the Red Cross Children's Hospital in Cape Town, South Africa over an 8-month period and included all children undergoing tonsillectomy or adenotonsillectomy. All resected tonsils were examined for the presence of Actinomycosis and any signs of significant cryptitis or active tonsillitis. A comparison was made in the incidence of Actinomycosis in children with obstructive sleep apnoea, recurrent tonsillitis or obstructive sleep apnoea and recurrent tonsillitis. The data was further analysed to determine the statistical significance of the association between Actinomycosis of the tonsils and age, sex and histopathological and clinical diagnosis. RESULTS: A total of 344 tonsils were analysed on 172 patients. We found 20 patients (11.6%) with Actinomycosis in the tonsils. The mean age of patients with Actinomycosis was 7.25 years and without Actinomycosis was 5.4 years (p=0.002). Most specimens (16) had no evidence of tissue reaction to Actinomyces, and their presence was found to be due to colonisation of the tonsils only. Actinomycosis was present in 11% of patients with obstructive sleep apnoea, 11% of patients with recurrent tonsillitis and in 9% with obstructive sleep apnoea and recurrent tonsillitis. The difference in incidence of Actinomycosis between these three groups (p=0.94), and between the recurrent tonsillitis group alone compared to the obstructive group (p=0.83), was not statistically significant. There was therefore no statistical significance found between Actinomyces and OSA+/- recurrent tonsillitis. CONCLUSIONS: There was no correlation found between the presence of tonsillar Actinomycosis and recurrent tonsillitis and/or obstructive tonsillar hypertrophy. Histopathologic findings showed no evidence of tissue reaction to Actinomyces and its presence was found to be due to colonisation of the tonsils only. The series did however show a statistically significant correlation between Actinomycosis colonisation and age with Actinomycosis being more common in older children, especially those over 5 years of age.     

Bacteriology of tonsil surface and core in children

The tonsils of 97 children undergoing tonsillectomy were studied to determine the correlation between surface culture swab and culture of tonsillar core. In many cases, pathogenic organisms were found in the tonsil core, despite the fact that surface cultures revealed only normal respiratory flora. The tonsil core cultures showed a high incidence of Hemophilus influenzae and Staphylococcus aureus, which was rarely reflected on surface culture. The study indicates that pharyngeal swab cultures do not reliably reflect the presence of pathogens in the tonsil core. The value of parameters such as history of recurrent bouts of tonsillitis and presence of erythema or cryptic debris on physical examination for predicting the differential bacteriology of the tonsil is studied. The implications for treatment of children with adenotonsillar hypertrophy are discussed.     

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults

ObjectiveThe study aims to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in adults with velopharyngeal valve insufficiency (VPI).MethodsThe study included 23 patients with VPI (grade I, II, III), with ages ranging from 19 to 45 years. Six patients had previously undergone simple palatoplasty for cleft palate, 8 patients had previously undergone adenotonsillectomy and 9 patients had previously undergone uvulopalatopharyngoplasty (UPPP). The procedure was done by implanting a piece of autologous tragal cartilage in the posterior pharyngeal wall. Patients were followed up for 24 months postoperatively. The evaluation of percent of speech intelligibility and grade of the closure of the velopharyngeal valve using video-nasopharyngoscopy was evaluated preoperatively and postoperatively.ResultsHighly statistically significant improvement in the grade of the closure of the velopharyngeal valve (P = 0.009) and percent of intelligibility (P = 0.001) was found after surgery. There were no postoperative airway obstruction or sleep apnea.ConclusionAugmentation of the posterior pharyngeal wall using tragal cartilage is an effective, safe and physiological surgical procedure in the management of VPI in adults who suffered hypernasality following palatal and oropharyngeal surgeries.     

The sensitivity and the specifity of rapid antigen test in streptococcal upper respiratory tract infections

Background

It is aimed to detect the sensitivity and specificity of rapid antigen detection of group A beta hemolytic streptococci from throat specimen compared with throat culture. The other goal of the study is to help in giving clinical decisions in upper respiratory tract infections according to the age group, by detection of sensitivity and positive predictive values of the rapid tests and throat cultures.

Materials and methods

Rapid antigen detection and throat culture results for group A beta hemolytic streptococci from outpatients attending to our university hospital between the first of November 2005 and 31st of December 2008 were evaluated retrospectively. Throat samples were obtained by swabs from the throat and transported in the Stuart medium and Quickvue Strep A [Quidel, San Diego, USA] casette test was applied and for culture, specimen was inoculated on 5% blood sheep agar and identified according to bacitracin and trimethoprim-sulphametaxazole susceptibility from beta hemolytic colonies.

Results

During the dates between the first of November 2005 and 31st of December 2008, from 453 patients both rapid antigen detection and throat culture were evaluated. Rapid antigen detection sensitivity and specificity were found to be 64.6% and 96.79%, respectively. The positive predictive value was 80.95% whereas negative predictive value was 92.82%. Kappa index was 0.91. When the results were evaluated according to the age groups, the sensitivity and the positive predictive value of rapid antigen detection in children were 70%, 90.3% and in adults 59.4%, 70.4%.

Discussion

When bacterial infection is concerned to prevent unnecessary antibiotic use, rapid streptococcal antigen test (RSAT) is a reliable method to begin immediate treatment. To get the maximum sensitivity of RSAT, the specimen collection technique used and education of the health care workers is important. While giving clinical decision, it must be taken into consideration that the sensitivity and the positive predictive value of the RSAT is quite lower in adult age group than in pediatric age group.     

A potential role for arginase in recurrent infections and hypertrophy of tonsillar and adenoidal tissue

Since arginase has been found to be an arginine-depleting and nitric oxide synthase-regulating enzyme, the present study was devised to examine hypertrophied and infected tonsil and adenoid arginase activity in relation to a metabolic arginase-nitric oxide pathway and its association with disease processes. Tissues were taken from 32 children undergoing adenotonsillectomy. There was a statistically significant difference between the two tissue enzyme activities, with tonsillar arginase activity being higher than the corresponding adenoidal tissue (P < 0.005). This suggests a potential role for tissue arginase activity as an outcome module and a contributing factor in chronic recurrent infection and hypertrophy of tonsillar and adenoidal tissues. Received: 8 October 1998 / Accepted: 22 April 1999     

Palatal eversion for the treatment of combined nasopharyngeal stenosis and tonsillar pillars adhesion

ObjectiveRarely the tonsillar pillars and the soft palate became adherent to the posterior nasopharyngeal wall by strong fibrous tissue due to excessive dissection and cauterization during surgery leading to nasopharyngeal stenosis. Therefore, many treatment modalities are being tried to cure this problem. The aim of this study is to explore our results of modifying the basic technique to accommodate those patients with combined nasopharyngeal stenosis and tonsillar pillars adhesions in one stage. Study Design: Case series.MethodsThis study was conducted on 10 patients with combined nasopharyngeal stenosis and tonsillar pillars adhesions after adenotonsillectomy. They were subjected to treatment by palatal eversion through dividing the soft palate in the midline to separate each pillar from the pharyngeal wall in continuation with each half of soft palate and removal of the fibrous tissue causing stenosis. This was followed by eversion and fixation of the two palatal divisions on either side to allow complete epithelialization of the stenotic area. Postoperative follow-up was done for one year by the flexible nasopharyngoscopy, perceptual speech analysis, and polysomnography.ResultsThe flexible nasopharyngosopic examination of the 10 patients at the end of post-operative period revealed a freely mobile soft palate with no nasopharyngeal stenosis or palatal fistula. Velopharyngeal function and speech assessment by perceptual speech analysis was normal in all 10 cases. No obstructive episodes were recorded in polysomnograms.ConclusionsPalatal eversion is a promising technique in the treatment of post-adenotonsillectomy of combined nasopharyngeal stenosis and tonsillar pillars adhesion. It is recommended to be used on a wider scale of patients and other indications as nasopharyngeal stenosis following uvulopalatoplasty and post nasopharyngeal radiotherapy. The level of evidence: 4 (case series).     

The role of the actinomyces in obstructive tonsillar hypertrophy and recurrent tonsillitis in pediatric population

Objective

To determine the prevalence of tonsillar Actinomyces in subjects with recurrent tonsillitis and those with obstructive tonsillar hypertrophy, and to determine the association between the presence of Actinomyces and tonsillar volume, and crypt abscess.

Subjects and methods

A prospective designed cross-sectional study consisted of 90 children subjects who underwent tonsillectomy or adenotonsillectomy for recurrent tonsillitis and obstructive tonsillar hypertrophy. The subjects of recurrent tonsillitis (Group A) and obstructive tonsillar hypertrophy (Group B) were compared to the presence of Actinomyces. The relationship between the presence of Actinomyces and the presence of crypt abscess, and tonsillar volume were also compared.

Results

Actinomyces was found to be significantly more prominent in obstructive tonsillar hypertrophy group (61.5%) compared to recurrent tonsillitis group (26.6%) (p < 0.001). Additionally, the mean tonsillar volume was significantly higher in tonsils with Actinomyces than those without (p < 0.001). The histopathological study revealed that there was no significant inflammatory response to the existence of Actinomyces.

Conclusion

According to the presented study, Actinomyces was seen more prominent in subjects with obstructive tonsillar hypertrophy compared those with recurrent tonsillitis. Furthermore Actinomyces had a pathological influence on tonsil size. This study showed there was a significant relation between Actinomyces and enlargement of tonsillar tissue. However, how causes tonsillar hypertrophy is not understood yet in tonsillar disease.     

Adenotonsillectomy or watchful waiting in patients with mild to moderate symptoms of throat infections or adenotonsillar hypertrophy: a randomized comparison of costs and effects

OBJECTIVE: To evaluate the cost-effectiveness of adenotonsillectomy compared with watchful waiting in Dutch children. DESIGN: Economic evaluation along with an open, randomized, controlled trial. SETTING: Multicenter, including 21 general and 3 university hospitals in the Netherlands. PARTICIPANTS: Three hundred children aged 2 to 8 years were selected for adenotonsillectomy according to routine medical practice. Excluded were children who had frequent throat infections and those with suspected obstructive sleep apnea. MAIN OUTCOME MEASURES: Incremental cost-effectiveness in terms of costs per episode of fever, throat infection, and upper respiratory tract infection avoided. RESULTS: Annual costs incurred in the adenotonsillectomy group were euro803 (the average exchange rate for the US dollar in 2002 was $1.00 = euro1.1, except toward the end of 2002 when $0.95 = euro100) and euro551 in the watchful waiting group (46% increase). During a median follow-up of 22 months, surgery compared with watchful waiting reduced the number of episodes of fever and throat infections by 0.21 per person-year (95% confidence interval, -0.12 to 0.54 and 0.06 to 0.36, respectively) and upper respiratory tract infections by 0.53 (95% confidence interval, 0.08 to 0.97) episodes. The incremental costs per episode avoided were euro1136, euro1187, and euro465, respectively. CONCLUSIONS: In children undergoing adenotonsillectomy because of mild to moderate symptoms of throat infections or adenotonsillar hypertrophy, surgery resulted in a significant increase in costs without realizing relevant clinical benefit. Subgroups of children in whom surgery would be cost-effective may be identified in further research. .     

Bacterial flora of the tonsillar surface versus tonsillar core in chronic tonsillitis

The purpose of the work was to present the frequency of isolation of particular bacterial species from smear samples obtained from the surface of the palatal tonsils and from aspirates of tonsillar core. The material involved 100 patients, 49 women and 51 men among them, who were qualified to tonsillectomy based on their history, otolaryngological examination and selected laboratory parameters and in whom bacteriological examination of smears taken from the right and left palatal tonsil were performed. The material obtained from superficial tonsillar smears and from tonsillar core aspirates was subject to bacteriological analysis. Frequency of isolation of particular bacterial species was performed. Higher detectability of beta-haemolytic streptococci was found in tonsillar core aspirates, as compared to superficial smears. Bacteriological analysis of palatal tonsil core aspirate was shown to be a good method of isolation of pathogenic microbial strains.     

The inflammation produced by corticosteroid inhalers in the pharynx in asthmatics

Objectives: To investigate inflammation of the pharyngeal mucosa caused by inhaled corticosteroids. Design: Prospective, cross‐sectional, single‐blinded study. Setting: University Hospital Aintree, Liverpool, UK. Patients: Fifty adults were recruited from two local general practices and from general ENT clinics at our University hospital. Patients were allocated to one of four groups according to use of inhaled corticosteroids and the presence of adverse local side effects. Main outcome measures: Scores achieved on a respiratory symptom questionnaire. Histological markers of inflammation and their correlation with pharyngitis. Statistical modelling included univariate and multivariate analyses, which included multiple linear and logistic regression, and discriminant analysis. Results: The regular use of inhaled corticosteroids predisposed subjects to hoarseness, weakness of voice, sore throat and throat irritation (P < 0.0001). Pharyngitis was significantly different between the groups (P < 0.0001). Furthermore, those not using an inhaled corticosteroid regularly had little or no clinically apparent pharyngitis, whereas those using an inhaled corticosteroid regularly had significantly higher pharyngitis scores (P = 0.0204). Similarly, weakness of voice (P = 0.0234), hoarseness (P < 0.001) and sore throat (P < 0.001) were also more common in those patients that used an inhaled corticosteroid on a regular basis. To our surprise, however, cellular markers of inflammation did not corroborate the appearances of clinical examination. We found that the five most important discriminators, between those that were using inhaled corticosteroid therapy regularly and those that were not, to be intra‐epithelial inflammatory cells (scdf ?1.2939); age (scdf 0.8389); use of a spacer device (scdf 0.5456); sore throat (scdf 0.4230) and throat irritation (scdf 0.4015). The groups were significantly different (P < 0.0001). The statistical model used, classified 68% of the cases correctly into their respective groups. Conclusions: Inhaled corticosteroids predispose to pharyngitis and an inflammatory infiltrate. However, the clinical diagnosis of pharyngitis does not correlate well with cellular inflammatory infiltrate and is therefore, not a reliable measure of underlying inflammation. We advocate caution in the use of pharyngeal erythema as a measure of underlying inflammation.     

Effect of adenotonsillectomy on middle ear status in children

OBJECTIVE: To determine the effects of adenotonsillectomy as compared with watchful waiting on the middle ear status of children. STUDY DESIGN: Randomized controlled trial. METHODS: We recruited 300 children between 2 and 8 years of age who were selected for adenotonsillectomy according to current medical practice. Excluded from the trial were children with very frequent throat infections (more than 6 per year) or obstructive sleep apnea. Participants were randomly assigned to either adenotonsillectomy or watchful waiting. Main outcome measure was the percentage of children with unilateral or bilateral otitis media diagnosed at the scheduled follow-up visits according to an algorithm combining tympanometry and otoscopy. RESULTS: The percentages of children in the adenotonsillectomy and watchful waiting group diagnosed with otitis media at baseline and at 3, 6, 12, 18, and 24 months were 27.7 versus 30.5, 16.8 versus 25.2, 18.3 versus 21.2, 12.3 versus 15.2, 17.6 versus 15.5, and 14.7 versus 10.3%, respectively (P < .10). In the subgroup of children selected for adenotonsillectomy predominantly because of recurrent or persistent otitis media, hearing loss, or recurrent upper respiratory tract infections (n = 111) and in the subgroup of children diagnosed with otitis media at inclusion (n = 82), the occurrence of otitis media did not differ significantly between the adenotonsillectomy and watchful waiting group during the entire follow-up period. CONCLUSION: We conclude that in a large proportion of children selected for adenotonsillectomy according to current medical practice, including those with otitis media or related complaints, no beneficial effect of adenotonsillectomy on middle ear status is to be expected.     

Complicaciones postoperatorias tras adenoamigdalectomía en niños con síndrome de apnea-hipopnea del sueño severo. ¿Requieren ingreso en unidad de cuidados intensivos?

Introduction and objectivesIn recent years, with the rise of sleep-disordered breathing, we have been seeing more articles related to post-operative complications after adenotonsillectomy in children with sleep apnea-hypopnea syndrome (OSAS), especially in those with severe sleep apnea. The objective of this study was to evaluate post-operative complications in children with severe OSAS compared to children who had adenotonsillectomy for a different reason, and establish whether they needed admission to an intensive care unit or not.MethodsAll children undergoing adenotonsillectomy in our hospital in the last 5 years were initially included in this study. Complications were analysed with a retrospective review.ResultsTwo hundred and twenty nine children admitted for adenotonsillectomy were finally included. In the whole group, complications occurred in 3.5% of children, 2.2% corresponding to respiratory complications. Children with sleep apnea (3.23% vs 1.47%, P = .39) or severe sleep apnea (3.77% vs 1.70%, P = .32) presented a higher incidence of respiratory complications, which was not statistically significant and was far below those published by other authors. All respiratory complications took place in the immediate post-operative period (operating theatre or anaesthesia recovery), with none in the paediatric ward.ConclusionsIn our population, children who undergo adenotonsillectomy, without any other comorbidities, malformation syndrome or neuromuscular disease, are more than 2 years old and have an immediate postoperative period without incidence, do not need to be systematically admitted to an intensive care unit, even if they present with severe OSAS.     

Comparative assessment of Helicobacter pylori colonization in children tonsillar tissues

Objective

The objective was to survey the results of RUT (rapid urease test) in children tonsillar tissues.

Methods

In a prospective clinical study 285 children (4-14 years) tonsillar tissue tested with RUT (rapid urease test) and histopathologic biopsy and simultaneously serum IgG Helicobacter pylori level was measured for all patients.

Results

One hundred and thirteen patients (39.6%) were positive to H. pylori in histopathologic examination. Forty patients (14%) had positive RUT and 15 patients had positive serum IgG anti-H. pylori level. In 40 patients the results in both histopathology and RUT were positive (P = 0.000) although in 172 patients the results in both histopatologhic and RUT were negative (P = 0.000).

Conclusions

This study showed that H. pylori was present in tonsillar tissue and RUT is not sensitive enough for diagnosis of H. pylori in tonsillar tissue. Indicating that H. pylori has a possible role in reservoir of H. pylori in children.     

Bacteriologic comparison of tonsil core in recurrent tonsillitis and tonsillar hypertrophy

OBJECTIVES: Although many bacteriology studies on tonsillar diseases have been completed, all have been confined to children and were characterized by a paucity of cases. The purpose of this study was to analyze the underlying bacterial pathogens in tonsillar disease. METHODS: A retrospective study was performed on 824 patients who underwent elective tonsillectomy with or without adenoidectomy. We analyzed the differences between the bacterial pathogens in recurrent tonsillitis and tonsillar hypertrophy with regard to age, season, and antibiotic sensitivity. RESULTS: Among 824 cases, 966 bacterial strains from the tonsil core were isolated. In recurrent tonsillitis, Staphylococcus aureus was the most common pathogen (30.3%), followed by Haemophilus influenzae (15.5%) and group A beta-hemolytic Streptococcus (Streptococcus pyogenes, 14.4%). In patients over 14 years of age, quite differently from other age groups, Klebsiella pneumoniae was isolated at a significantly higher percentage. In tonsillar hypertrophy, H. influenzae was isolated most commonly (31.4%) regardless of age, followed by S. pyogenes (24.2%), S. aureus (22.9%), and Streptococcus pneumoniae (12.6%). Furthermore, mixed infection was common because of its high resistance to penicillin. In both groups, S. pneumoniae was more common in younger patients, whereas K. pneumoniae was relatively common in adults. We found no differences in the detection rate by season; however, H. influenzae was frequently isolated in the tonsillar hypertrophy group regardless of seasonal variations. We also found no difference in the antibiotic sensitivity between the two groups; however, strains resistant to penicillin were relatively prevalent and showed a high sensitivity to third-generation cephalosporin. CONCLUSIONS: We observed some differences in the types of bacteria in the tonsillar core between the recurrent tonsillitis and tonsillar hypertrophy groups. Our study indicates that essential bacteria have been changing and, thus, we need to change our choice of antibiotics.     

Primary oropharyngeal tuberculosis causing destruction of uvula—A rare presentation

Despite the contact of pulmonary secretions and the mucous membranes of the upper respiratory tract with a high bacillary load, tuberculosis of the head and neck area, excluding laryngeal forms, is exceptional and constitutes only 2–6% of extra pulmonary tuberculosis and 0.1–1% of all forms of tuberculosis. Oral cavity tuberculosis is uncommon, out of which primary pharyngeal tuberculosis is extremely rare. We present a case of an ulcerative lesion in a 7-year-old female subsequently proven to be primary oropharyngeal tuberculosis. There was an erosion of uvula and posterior soft palate. There was also an ulcerated area on adjacent area of left tonsillar fossa with slough over posterior pharyngeal wall.     

Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography

OBJECTIVE: To evaluate the outcome of adenotonsillectomy for obstructive sleep apnea (OSA) in children using objective data from polysomnography supplemented by subjective proxy reports from the OSA-18 quality of life instrument. STUDY DESIGN: Prospective cohort study. METHODS: Children 3 to 14 years of age with OSA diagnosed principally on the basis of polysomnography as having an obstructive apnea/hypopnea index (AHI) of 5 or greater underwent adenotonsillectomy. OSA was classified as mild (AHI > or = 5 < 10), moderate (AHI > or = 10 < 20), or severe (AHI > or =20). Children enrolled in the study also had postoperative polysomnography 3 to 6 months after surgery. Caregivers completed the OSA-18 survey before surgery and within 6 months after surgery. Pearson correlation was used to compare the pre- and postoperative AHI values with the pre- and postoperative OSA-18 total scores. SAS procedures (SAS Corp., Cary, NC) were used for statistical analyses. A P value less than or equal to .05 was considered significant. RESULTS: The study population included 79 healthy children, 40 of who were male. The mean age was 6.3 (range, 3.0-14.0) years. Only tonsillar size was correlated significantly with a high preoperative AHI. For all children, the preoperative AHI value was higher than the postoperative value. The mean preoperative AHI for the study population was 27.5, whereas the mean postoperative AHI was 3.5. This change was highly significant (P < .001). The percentage of children with normal polysomnography parameters after adenotonsillectomy ranged from 71% to 90% as a function of the criteria used to define OSA. It was highest when an obstructive apnea index less than 1 was used and lowest when an AHI less than 1 was used to define resolution of OSA. Overnight respiratory parameters after adenotonsillectomy were normal for all children with mild OSA. Three (12%) children with moderate preoperative OSA, and 13 (36%) children with severe preoperative OSA had persistent OSA after adenotonsillectomy. Resolution of OSA occurred in all children with a preoperative AHI less than or equal to 10 and in 73% of children with a preoperative AHI greater than 10. The mean total OSA-18 score and the mean scores for all domains showed significant improvement after surgery (P < .001). The preoperative AHI values had a fair correlation with the preoperative total OSA-18 scores (r = 0.28), but postoperative AHI values had a poor correlation with the postoperative total OSA-18 scores (r = 0.16). Caregivers reported snoring some, most, or all of the time in 22 (28%) children; this group included all children with persistent OSA. CONCLUSIONS: Adenotonsillectomy for OSA results in a dramatic improvement in respiratory parameters as measured by polysomnography in the majority of healthy children. Quality of life also improves significantly after adenotonsillectomy for OSA in children. However, the correlation between improvements in respiratory parameters and improvements in quality of life is poor. Severe preoperative OSA is associated with persistence of OSA after adenotonsillectomy. Postoperative reports of symptoms such as snoring and witnessed apneas correlate well with persistence of OSA after adenotonsillectomy.     

Cytokine polymorphisms predict the frequency of otitis media as a complication of rhinovirus and RSV infections in children

Previous studies suggested that the otitis media (OM) complication rate of viral upper respiratory infection (vURI) is conditioned by genes affecting cytokine production. Two hundred and thirty children (114 male; 187 White, 25 Black; aged 1–9.3 years, average = 3.6 ± 1.6 years) were prospectively followed over the typical cold season for cold-like illness and OM. Nasopharyngeal secretion samples collected during cold-like illness and OM were assayed for upper respiratory viruses and buccal samples were assayed for TNFα (−308), IL-10(−1082, −819, −592), IL-6 (−174) and IFN-γ (+874) polymorphisms. Logistic regression was used to identify genotypes that predict OM coincident with RSV and rhinovirus (RV) infection. Of the 157 children with RV detection (79 male; 132 White, 13 Black, 12 Other; aged 3.6 ± 1.5 years), simple logistic regression identified age (B = −0.34, Z = −2.8, P < 0.01, OR = 0.71), IL-6 (B = −0.76, Z = −3.3, P < 0.01, OR = 0.47) and IL-10 (B = 0.49, Z = 2.0, P = 0.05, OR = 1.6) as significant predictors of OM coincidence. A more complex logistic regression model for RV detection that included selected OM risk factors identified these factors as well as the TNFα genotype, OM history, breastfeeding history and daily environment as significant predictors of OM coincidence. Of the 43 children with RSV detection (21 male; 35 White, 5 Black, 3 Other, aged 3.9 ± 1.7 years), logistic regression identified IL-10 (B = 1.05, Z = 2.0, P = 0.05, OR = 2.9) as a significant predictor of OM coincidence. New OM episodes coincident with evidence of RSV and RV infection were significantly more frequent in children with high production IL-10 phenotypes. The low production IL-6 and high production TNFα phenotypes also contributed to OM risk during RV detection. Cytokine polymorphisms may be one of an expectedly large number of genetic factors contributing to the known heritability of OM.