An adenotonsillectomy, or surgical removal of the tonsils and adenoids, leads to an improvement in behavior and sleep for pediatric patients diagnosed with sleep disordered breathing has been revealed in a study from the University of Kansas Medical Center and School of medicine.

Sleep disordered breathing (SDB), is usually caused by enlarged tonsils causing upper airway obstruction during sleep. In children, the terms “obstructive sleep disorders” (OSD) and “sleep disordered breathing” (SDB) are more widely used as opposed to obstructive sleep apnea syndrome (OSAS) because the former two terms recognized that SDB is a spectrum of sleep-related breathing disorders including primary snoring, upper airway resistance syndrome, obstructive hypoventilation, and OSAS (the most severe aspect of the spectrum). Traditionally, OSAS is identified only by a sleep study, and while the prevalence of OSAS has been reported to range from 0.7 to three percent, the prevalence of snoring and clinical suspicion of SDB in children may be high as 11 percent.

How SDB affects childhood development and behavior, specifically hyperactivity and inattention, has been addressed in past research. Using sleep studies or polysomnograph, and parental surveys, one study showed that while SDB was not more likely to occur among children with significant ADHD symptoms, it is significantly highly prevalent among children with mild hyperactive behavior.

Habitual snoring and SDB have been associated with ADHD as well as neurocognitive impairment and poor school performance, leading to a suggestion that treating SDB and habitual snoring may eliminate ADHD in a subset of children. Unlike OSAS which is defined by specific apnea-hypopnea index based on polysomnography, SDB may be diagnosed clinically and not consistently meet PSG criteria for an obstructive sleep breathing disorder.

A questionnaire specific for predicting SDB and improvement after surgery, would bridge the gap between objective sleep study data on every child with nocturnal airway obstructions on one hand and clinical suspicion of SDB in children at the other end of the spectrum. Such a questionnaire is the Pediatric Sleep Questionnaire (PSQ), previously developed by Dr. Chervin and colleagues at the University of Michigan, uses subscales in SDB, snoring, sleepiness, and behavioral problems which has shown good validity and reliability for predicting SDB when compared with polysomnography. The PSQ may be used as a tool in clinical research when polysomnography may not be feasible.

The Connor’s Parent Rating Scale-Revised Short (CPRS-RS) survey has been proved effective to assess behavior in subjects before and after treatment intervention. Both the CPRS-RS and PSQ were used by Kansas otolaryngologist - head and neck surgeons to determine change in sleep and behavior before surgery and again at six months after adenotonsillectomy, as well as to identify any correlations between sleep and behavior pre and post surgical intervention in children with SDB, without using sleep study or polysomnography. The authors of “Improved Behavior and Sleep After Adenotonsillectomy in Children with Sleep Disordered Breathing,” are Julie L. Wei MD, and Robert A. Weatherly MD, both from the Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine; Matthew S. Mayo PhD, and Holly J. Smith, at the Center for Biostatistics and Advanced Informatics, University of Kansas Medical Center; and Matt Reese PhD, with the Developmental Disabilities Center, University of Kansas Medical Center. Their findings will be presented at the 21st Annual Meeting of the American Society of Pediatric Otolaryngology, being held May 20-22, 2006, at the Hyatt Regency Hotel in Chicago, IL.

Methodology: Within a pediatric otolaryngology practice, 117 consecutive children clinically diagnosed with sleep disordered breathing and scheduled for surgical removal of the adenoids and tonsils were enrolled as the research subjects. A convenience sample of caregivers of patients, age two to 17, undergoing adenotonsillectomy for SDB were eligible and asked to participate. Patients were excluded if the primary reason for adenotonsillectomy was recurrent infections. Data were collected on the day of the surgery and at six months following the surgery date. This study was modeled after previous studies examining the quality of life (QOL) improvement after adenotonsillectomy. Caregivers completed two questionnaires at both time intervals: the CPRS-RS as well as the PSQ.

Changes in age appropriate T-scores for all four CPRS-RS behavior categories (oppositional, cognitive problems/inattention, hyperactivity, and Conner’s ADHD index) were determined for each subject pre- and post-operatively. Changes in PSQ scores from select 22-item sleep-related breathing disorder (SRBD) subscale were also determined.

Results: The results offered evidence that before surgery, the mean PSQ score for the 117 patient was 0.56, the scale is between 0 and 1, with scores approaching 1 representing the most severe disturbance in sleep. 112/117 (95.73 percent) had a PSQ score of >0.33, which suggests high risk for SDB, and 5/117 (4.27 percent) had a PSQ score of < 0.33. At six-months after adenotonsillectomy, the mean PSQ score for the 71 patients who completed the study was 0.12[0.14]. Of these 71 patients, 7(9.86 percent) still had a PSQ score of >0.33, while 64 (90.14 percent) had a PSQ score of < 0.33. For the CPRS-RS scores, a reduction was noted in aged and sexed norm T-scores for all four behavior categories (oppositional, cognitive problems/inattention, hyperactivity, and ADHD index), close to one standard deviation from their preoperative score which is clinically significant. Also, the researchers found that the higher the baseline T-score, the greater the reduction in T-score after surgery. Correlations were found between behavior and sleep both before and after adenotonsillectomy.

Conclusions: The study supports associations between adenotonsillectomy to alleviate upper airway obstruction and changes in both sleep and behavior, as evidenced by results in the PSQ and CPRS-RS surveys. At six months after adenotonsillectomy, patients experience improvement in both sleep and various behavior categories as measured by these instruments.