2.1. Case Study
The study included 5000 patients aged between 3 and 12 years old, consecutively led to the otolaryngologic multispecialty department of the AORN (hospital of national relevance) “Santobono-Pausilipon” in Naples from January 2014 to June 2018, who were affected with OSAS linked to adenotonsillar hypertrophy.
The study was conducted excluding patients with the following: neuro-muscular pathologies; major craniofacial anomalies, both isolated and linked to syndromes; obesity; recurring tonsil infections; and documented allergy history (skin prick test) with respect to common air allergens.
All patients underwent the following:
- I.
Anamnesis
This was conducted in order to evaluate the medical history of snoring, respiratory pauses during sleep, drowsiness and day-time hyperactivity, school performance, and behaviour.
- II.
Survey OSA-18 specific for SBD (obstructive sleep-disordered breathing)
During the anamnesis we distributed a survey borrowed from the literature (OSA-18) to the patients’ parents. This aimed to define the quality-of-life (QoL) alteration in the patients, as the objects of the study, relative to the obstructive symptomatology they presented [
9,
10,
11,
12,
13].
The survey consisted of 18 questions regarding 5 fields: sleep disorders, symptomatology, emotional impact, daily activities, and parents’ worries. Each of these was given a score from 1 to 7, with a final summed score that could vary from 18 to 126.
- -
A score below 60 implied a minor impact on the quality of life.
- -
A score between 60 and 80 meant a moderate impact.
- -
A score above 80 meant a major negative impact on the patient’s quality of life.
By calculating the average of the single values, we found the following:
- -
1873 patients (37.46%) presented values < 60 (minor impact);
- -
2408 patients (48.16%) presented values between 60 and 80 (moderate impact);
- -
719 patients (14.38%) presented values between 80 and 105 (major impact).
- III.
Upper respiratory tract endoscopy:
All the patients underwent a complete otolaryngologic visit, on an outpatient basis; specifically, an upper respiratory tract evaluation was performed through the employment of an Olympus System® flexible (Olympus Europa SE & Co. KG, Wendenstraße 20, 20097 Hamburg) video-endoscope (with a diameter of 2.7 mm for patients ranging from 3 to 6 years, and 3.5 mm for patients older than 6 years) equipped with a chip on the tip, connected to a camera that was able to decode the images collected. All the visits were observed in order to evaluate the pharynx anatomical district. The visits were performed without administering local and/or general anaesthetics.
In order to define the adenoid hypertrophy degree, we referred to the most commonly used classification system, devised by Parikh et al. [
14] which identifies 4 obstruction degrees based on the existing relationship between the hypertrophic adenoids, vomer, soft palate, and torus tubarius:
- -
First-degree obstruction—adenoid volume limited to the nasopharynx roof;
- -
Second-degree obstruction—adenoids reach the upper half of the nasopharynx;
- -
Third-degree obstruction—adenoid volume covers ¾ of the nasopharynx space;
- -
Fourth-degree obstruction—adenoids completely obstruct the nasopharynx.
For tonsil hypertrophy diagnosis, the examination employed was the pharynx endoscopy. This employs the Mackenzie classification [
14], which also identifies 4 degrees:
- -
1st degree—intravelic tonsils, completely behind the front tonsillar pillar;
- -
2nd degree—lightly hypertrophic tonsils, barely protruding from the front tonsillar pillar;
- -
3rd degree—hypertrophic tonsils, occupying ¾ of the available space;
- -
4th degree—extremely hypertrophic tonsils, completely obstructing the aero-digestive tract (kissing tonsils).
The procedure highlighted the following:
- ○
1873 patients (37.46%) presented 1st–2nd degree adenotonsillar hypertrophy;
- ○
3127 patients (62.54%) presented 3rd–4th degree adenotonsillar hypertrophy.
Thus, following this first set of analyses, we selected 1873 patients (37.46%) with 1st–2nd degree adenotonsillar hypertrophy with a related score on the OSA18 survey highlighting a modest impact on quality of life (average score < 60). Together with a minor symptomatology, this ensured that the patients would only undergo the surgical procedure (nasal corticosteroids and ionised nasal irrigation with hypertonic and isotonic saline solutions) and would be excluded from the study.
In the 3127 remaining patients (62.54%), the rhinopharynx endoscopy highlighted a 3rd–4th degree lymphatic hypertrophy and all the patients had a survey score > 60. In particular, 2408 (48.16%) patients presented a score between 60 and 80 (moderate impact) and the remaining 719 (14.38%) presented a score between 80 and 105 (major impact), with an average score of 89.5. This last group was also selected to undergo night pulse oximetry in order to evaluate the OSAS degree and undergo surgery [
14,
15,
16,
17,
18,
19,
20] (
Table 1).
- IV.
Night pulse oximetry
The exam was carried out using a pulse oximeter, which allowed us to measure blood oxygen saturation (SpO2). The exam was carried out at the patient’s residence using a Gima Oxy 50 device, with result readings performed by medical personnel from the pneumology multispecialty department of AORN “Santobono-Pausilipon” the morning after the exams. The track was evaluated using the McGill Oximetry Scoring System (MOS), following the criteria set by Nixon et al. This system was devised as a screening method to select patients with lymphatic tissue hypertrophy and direct them to have an adenotonsillectomy. It consists of a tool diagnostic score, which, starting from the number of desaturations < 90% and the number of cluster desaturations, divides up the patients by desaturation degree. Desaturation is considered a saturation reduction of at least 4% relative to the basal value, and cluster desaturation describes the presence of at least 5 desaturations in a period of time between 10 and 30 min. Therefore, the examination yields positive results in the presence of the following:
- ○
3 desaturation clusters or at least 3 desaturations < 90% (during the night recording) (Category 2, minor OSAS);
- ○
4 desaturations < 85% (Category 3, moderate OSAS);
- ○
4 desaturations < 80% (Category 4, major OSAS).
It yields negative results in the absence of desaturation clusters and in the absence of desaturations < 90% [
15,
16,
17].
In our case study:
- ○
1879 patients (60.09%) presented Category 3, moderate OSAS;
- ○
1248 patients (39.91%) presented Category 4, major OSAS.
All patients with 3rd–4th degree lymphatic hypertrophy thus presented moderate-major OSAS (
Figure 1).
2.4. Surgery Type
The technique employed for intracapsular tonsillotomy consisted of moving the patient into the Rose position, ensuring exposure of the lower pole of both tonsils, and also using lateral mouth openers in order to facilitate greater tonsil exposition. The tool employed for tonsillotomy was a microdebrider with a 4 mm tip set to oscillating mode, with a frequency between 1000 and 3000 rpm. Bipolar forceps were used for haemostasis, as the microdebrider’s tip lacked monopolar diathermy. As for the technique details, after having positioned a retractor at the level of the anterior tonsillar pillar, the tonsillotomy began, starting from the posterior tonsillar pillar. Taking care not to damage the posterior tonsillar pillar, we then proceeded with progressive excision of the lymphatic tissue, thus leaving only a minimal part at the location, with the role of protecting the capsule. We focused on avoiding damage to the uvula, the tonsillar capsule, and the tonsillar pillar.
The extracapsular tonsillectomy used for Group B was carried out “cold” through scalpel dissection, surgical scissors, an ENT elevator, and a snare. In the Rose position, a McIvor mouth opener was used to achieve adequate oropharynx exposition. The tonsillectomy consisted of the incision of the anterior tonsillar pillar with a tonsil scalpel. After having identified the tonsillar capsule, we proceeded with the dissection using an ENT elevator, from the superior pole to the inferior pole. Lastly, the tonsil was removed completely using the snare. After the dissection and the haemostasis control, the same procedure was applied for the excision of the contralateral tonsil. After the haemostasis, the surgery was completed with the traditional “noose” suture in polyglactin 910 (vicryl rapid®) or with bipolar forceps for cauterisation of possible bleeding points (selective bipolar coagulation in order to reduce thermic lesions to the surrounding mucous membrane and muscles to a minimum) or both (mixed technique). In both groups, adenoidectomy was also performed using the Laforce adenotome and/or Beckmann curette, and haemostasis was performed through bipolar diathermy.
2.5. Postoperative Results Evaluation
The parameters considered in order to evaluate the effectiveness of the two different surgery techniques were as follows:
- I.
The presence of possible postoperative complications, mainly represented by pain and perioperative bleeding;
- II.
The degree of postoperative respiratory obstruction, comparing it with the preoperative value through pulse oximetry; carried out 6 months after surgery;
- III.
Tonsillar hypertrophy relapse in Group A and/or the presence of residuals in Group B with clinical evaluation taking place 1 month, 6 months, and 1 year after surgery;
- IV.
Postoperative quality of life assessed through providing the patient’s parents with the same survey provided before the surgery 1 month, 6 months, and 1 year after the surgery.
In order to understand the presence of possible postoperative complications, all patients were subjected to pain evaluation two days following surgery. Pain was evaluated through the Wong–Baker scale, consisting of 6 faces, from a smiling face, corresponding to “no pain”, to a crying face, corresponding to “worst pain possible”. The scale was administered to each child, asking them to point out the face corresponding to the pain they felt. Each choice corresponded to a number from 0 to 5. Usually, the term “ill-being” is used for children of 3 to 5 years old and the term “pain” is used for older children [
22].
Relative to haemorrhagic complications, all the cases of early (<24 h) or late (>24 h) postoperative bleeding, in which the patient needed revision surgery with general anaesthesia, were considered. In the case of bleeding, we proceeded with diathermic coagulation of the bleeding vessels or tonsillar pillar suturing, applied with a curved needle, where a nylon or silk thread sutured the two pillars together.
Evaluation of the postoperative respiratory obstruction degree was effectuated through a new pulse oximetry evaluation 6 months after the surgery. Lastly, the postoperative quality-of-life variations and the clinical evaluation of tonsillar hypertrophy relapse (in Group A) or the presence of surgical residues (in Group B) were evaluated with a follow-up that consisted of an otolaryngologist evaluation with upper respiratory tract endoscopy and OSA-18 survey administered to the parents after 1 month, 6 months, and 1 year from the surgery.