European Journal of Cardiovascular Medicine

About 2% to 5% of children with obstructive sleep apnoea hypopnea syndrome (OSAHS) will become seriously ill. This number peaks between the ages of 2 and 5.[1] link between OSAHS and obesity is that fat can make OSAHS symptoms worse.[2] OSAHS can show up in the form of sleep problems, trouble focussing, memory loss, and the effects that have on normal growth and psychological behaviour.[3] Kids with moderate to serious OSAHS who have swollen tonsils or adenoids should have surgery. Traditional tonsil removal and cutting can be done with an ultrasound knife, a laser, a microwave, or plasma.[4,5] A low-temperature plasma knife works by using an electromagnetic wave with a certain frequency to set off a plasma. The plasma can cut, burn, and stop bleeding in tissues. A low-temperature plasma knife is said to cause less damage and blood, faster healing, and mild pain after surgery, so it is being used more and more.[6] The goal of this study is to look into how tonsillectomy with low-temperature plasma affects the growth and mental health of OSAHS kids.

Study Design and Setting

This was a prospective observational study conducted over a period of one year in the Department of ENT at World College of Medical Sciences and Research Hospital, Jhajjar. The study focused on evaluating the role of tonsillectomy in the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) in pediatric patients.

Study Population

A total of 100 pediatric patients diagnosed with OSAHS were included in the study. The inclusion criteria were:

• Age between 3 and 14 years
• Clinical diagnosis of OSAHS based on history, symptoms, and clinical examination
• Presence of tonsillar hypertrophy (Brodsky score ≥2)
• Patients undergoing tonsillectomy with or without adenoidectomy

Exclusion criteria included:

• Previous history of upper airway surgery
• Craniofacial anomalies or neuromuscular disorders
• Patients with other comorbid conditions affecting sleep patterns

Preoperative Evaluation

All patients underwent a thorough clinical examination and assessment, which included:

• Detailed history of snoring, witnessed apneas, restless sleep, and daytime symptoms
• Mallampati scoring for airway assessment
• Brodsky grading for tonsil size evaluation
• Preoperative nasofibroscopy for assessing adenoid hypertrophy
• Radiological investigations, including X-ray or computed tomography (CT) of the nasopharynx when indicated
• Routine preoperative biological assessments

Surgical Intervention

Patients underwent conventional cold dissection tonsillectomy under general anesthesia. If adenoid hypertrophy was significant, adenoidectomy was performed simultaneously. The surgical technique, intraoperative complications, and duration of the procedure were documented.

Postoperative Assessment and Follow-up

Patients were monitored for early and late postoperative complications, including bleeding, pain, and infection. The effectiveness of surgery was assessed based on improvement in OSAHS symptoms, parental reports, and postoperative follow-up at 1, 3, and 6 months. Any residual symptoms or recurrence of OSAHS signs were recorded.

Data Analysis

All collected data were analyzed statistically using appropriate software. Descriptive statistics were used for frequency distributions, while paired statistical tests were applied to compare preoperative and postoperative findings.

Table 1. Distribution of Patients Admitted According to the Reasons for Consultation (N = 100)

Nighttime Signs

Daytime Signs

Accompanying Signs

Table 1 presents the distribution of 100 patients admitted according to their reasons for consultation, categorized into nighttime, daytime, and accompanying signs. Among the nighttime signs, nighttime snoring (99%), nasal obstruction (97%), and mouth breathing (97%) were the most commonly reported symptoms. Other notable nighttime signs included micro-awakenings during the night (90%), apnea/hypopnea (88%), and head in hyperextension (73%), while respiratory difficulty (39%), restless sleep (29%), and sweating (16%) were observed in fewer cases. Less frequently noted signs were enuresis (6%) and pallor (4%). Regarding daytime signs, the most common complaints were asthenia upon waking (89%), drowsiness (71%), and morning headaches (67%), while hyperactivity (32%), irritability (21%), and lack of concentration (2%) were reported in fewer patients. Rare cases included behavioral disorders (2%), growth delay (1%), developmental delay (1%), and learning difficulties (1%). The accompanying signs most frequently observed were fever (63%) and swallowing difficulties (60%), followed by rhinorrhea (31%). Cough (2%) and other symptoms such as adenoid facies, anorexia, eyelid edema, and vomiting (2%) were less commonly reported. This distribution highlights that nighttime symptoms, particularly snoring and nasal obstruction, were the most frequent complaints among the study population.

Table 2. Distribution of Patients Received According to the Results of the ENT Examination (N = 100)

Rhinological Examination (Anterior Rhinoscopy)

Nasofibroscopy

Otological Examination

Table 2 presents the distribution of 100 patients based on the results of the ENT examination, categorized into rhinological, nasofibroscopic, and otological findings. In the rhinological examination (anterior rhinoscopy), the most commonly observed condition was hypertrophy of the lower turbinates (86%), followed by a pale mucous membrane (54%) and mucous rhinorrhea (53%). Purulent rhinorrhea was detected in 10% of cases. Nasofibroscopy findings revealed a high prevalence of enlarged adenoids (97%), while cavum lesions were observed in only 1% of patients, and choanal atresia was not detected in any case. In the otological examination, the most common findings included the presence of an earwax plug (15%) and an earwax blade (5%), while recurrent acute otitis media (2%), chronic otitis media with an open eardrum (1%), otitis externa (1%), and seromucous otitis (1%) were observed in a smaller number of cases. These findings indicate that enlarged adenoids and hypertrophy of the lower turbinates were the most prevalent abnormalities in the study population.

Table 3. Distribution of Patients Received According to the Etiologies/Risk Factors (N = 100)

Table 3 outlines the distribution of 100 patients based on etiologies and risk factors associated with their condition. The most frequently identified cause was adenoid vegetation (71%), closely followed by hypertrophic tonsillitis (68.6%). Other notable conditions included hypertrophic rhinitis (15%) and pharyngitis (11%). Less commonly observed factors were nasal polyposis, septal deviation, choanal atresia, foreign bodies in the nasal cavity, and obesity, each affecting 1% of the patients. These findings highlight that adenoid vegetation and hypertrophic tonsillitis were the predominant underlying conditions in the study population.

study. At the ENT-Head and Neck Surgery department at Ignace Deen National Hospital, the goal was to look into how adenotonsillectomy is used to treat OSAHS in kids. We had some problems with this study, like not being able to do polysomnography and some parents not wanting their kids to have surgery. Even with these problems, we were able to get answers that we compare to data from other sources. In our study, out of a total of 1594 patients seen in consultation, we recorded 100 cases of OSAHS in children, representing a hospital frequency of 6.3%. is higher than what Lenouvel I et al. [7] found in France (2019), where they found a frequency of 1% to 4%. This might have something to do with the surroundings or way of life of the people, or it could be because they are exposed to things that make allergies and recurrent rhinosinusitis more likely. People between the ages of 0 and 5 (55%) were most affected, with an average age of 5.1 ± 3.8 years. Our average age was about the same as Blanc F et al. [8] (2019) in France, who found an average age of 5.5 ± 2.6 years. However, it was younger than Gachelin E et al. [9] (2015) in France, who found an average age of 10.5 ± 3.3 years. This may be because of the increased size of lymphoid tissue in the ENT area, which marks the time when the body gets used to getting repeated rhinosinusitis infections on the one hand, and the fact that kids' upper lungs are smaller than adults' [10]. With a sex ratio of 2.28, we saw that most of the people were men (69.6%). It's similar to what Gachelin E et al. [9] found in France in 2015, where they also found a male majority (sex ratio of 1.04). It's different from what Manel Ben H et al. [11] found in Tunisia (2018), where they found that women were more common than men (0.81). Our observations are analogous to those of Manel Ben H et al. [11] in Tunisia (2018), which indicated that nightly snoring, memory disturbances, and morning weariness were reported at rates of 87%, 73%, and 66%, respectively. In the study by Gachelin E et al. [9] conducted in France (2015), snoring, nasal blockage, and morning headaches were the primary reasons for visits, comprising 60%, 41.1%, and 14.4%, respectively. Parents of children with OSAHS most frequently describe symptoms of snoring and respiratory difficulties during sleep. Nonetheless, snoring has low specificity for obstructive sleep apnea-hypopnea syndrome (OSAHS), and clinical symptoms alone are insufficient to effectively differentiate OSAHS from normal snoring [12]. Additional symptoms during sleep encompass paradoxical breathing (characterised by inward movement of the chest wall during inhalation), gasping, restless sleep, frequent awakenings, or interruptions in breathing. The duration and frequency of these symptoms must be assessed, together with the level of persistence (e.g., intermittent, present just during illness, or constant). The voice may exhibit hyponasality due to nasal blockage or muted quality due to tonsillar hypertrophy, with tonsil size evaluated using the Brodsky score [13].

Assessment of the head and neck may uncover further indications regarding the origin of upper airway obstruction, including retrognathia, macrognathia, midfacial hypoplasia, nasal obstruction, and macroglossia. Although cardiac defects are infrequent and typically arise in the context of severe chronic illness, infants may develop systemic or pulmonary hypertension [14], which can manifest as significant closure of the pulmonary valve (audible P2). In young babies and children having a non-contributory physical examination, neurological impairments impacting the muscular tone of the upper airways must be excluded. Additional prevalent nocturnal manifestations encompass diaphoresis and enuresis. Excessive daytime somnolence is uncommon [15]. In a study of 100 patients, rhinosinusitis was the most commonly reported history, affecting 77 patients, followed by tonsillar hypertrophy in 60 patients and adenoid vegetation in 32 patients. The high prevalence of these conditions could be attributed to recurrent infections. Regarding the Brodsky score, which evaluates tonsil volume, grade 4 was the most frequently observed, occurring in 59 patients. With respect to the Mallampati score, class 2 predominated in our study, affecting 94 out of 100 patients.

 In our study, class 2 of the Mallampati score predominated at 93.7%. This score evaluates the correlation among the tongue volume, soft palate, and oral cavity. In the 2021 study by Heath D et al. in Canada, [16]children with tonsil sizes classified as 3 were 3.41 times more likely to undergo adenotonsillectomy than those with tonsils classified as 1, whereas children with tonsil sizes classified as 4 were 7.96 times more likely to have adenotonsillectomy compared to those with tonsils classified as 1. Fibroscopic

The examination delineates the dimensions of adenoid hypertrophy, the placement of the soft palate and tonsils, their mobility, laryngeal morphology, the size of the tongue base, and the dynamics of swallowing and phonation. The procedure can be conducted in either a seated or supine position. Whenever feasible, a paediatric nasofibroscope with a narrow diameter (2.2 mm) should be utilised. [17] The main etiologies encountered in our series were adenoid vegetation in 71 out of 100 patients and hypertrophic tonsillitis in 69 out of 100 patients. Our findings align with those of Camoina A et al. [18] in France, who indicated that adenoid hypertrophy (78%) and tonsillar enlargement (67%) were the primary aetiologies. The main preoperative exploratory examinations performed in our study were biological assessments in 100 out of 100 patients, nasofibroscopy in 51 patients, and computed tomography (CT) and X-rays of the nasopharynx in 47 patients. The majority of radiological exams are superfluous during routine consultations. The volume of adenoid tissue is optimally assessed using nasofibroscopy. An X-ray of the nasopharynx may be recommended for obstinate children, demonstrating a strong correlation with adenoid volume [19]. Individuals with intricate craniofacial anomalies may gain from cephalometric assessment and a CT scan of the facial skeleton, facilitating the examination of the nasal canals, rhinopharynx, facial region, mandibular morphology, glossoptosis, and pharyngeal volume. These examinations are also beneficial in the preoperative evaluation for midfacial advancement surgery or mandibular distraction.

Adeno-tonsillectomy was the main surgical intervention performed in our series, occurring in 45 out of 100 patients. Our statistics were analogous to those of Oillic H et al. [20], who indicated that adenotonsillectomy was the predominant surgical intervention employed in the majority of patients, with rates of 68% and 90%, respectively. Adenotonsillectomy is the most frequently cited procedure for the surgical management of ENT-origin obstructive sleep apnea-hypopnea syndrome (OSAHS) in paediatric patients [21]. The remission of apneic symptoms can attain up to 88% [21]. Adenoid-tonsillar hypertrophy is the predominant aetiology of obstructive sleep apnea-hypopnea syndrome (OSAHS) of otolaryngological origin in paediatric patients. This surgical procedure increases the capacity for airflow in the upper airways [22]. Nearly all children (99.0%) experienced simple postoperative outcomes. This conclusion is consistent with the findings of Oillic H et al. [20], who similarly documented straightforward postoperative results in their cohort. These findings emphasise the vital importance of surgical intervention in the management of OSAHS, especially in paediatric patients. It must be conducted by qualified otolaryngologists. Multidisciplinary collaboration is customary for patients of persistent obstructive sleep apnea-hypopnea syndrome (OSAHS).

OSAHS is a progressively prevalent condition in the paediatric demographic, especially among school-aged males. The symptoms are diverse and non-specific, primarily characterised by nocturnal snoring, nasal blockage, and oral respiration. Management is contingent upon the underlying aetiologies, especially those connected to ENT, with adenotonsillectomy serving as the primary intervention that markedly enhances patients' clinical condition. A multicenter study is essential to assess the quality of life in children who have had tonsillectomy  for Obstructive Sleep Apnoea Hypopnea Syndrome. 

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