Improvement in the quality of life of children after adenotonsillectomy

Abstracts

O aumento de volume das tonsilas palatina e faríngea é um dos problemas mais freqüentes do consultório do otorrinolaringologista e é a principal causa de apnéia obstrutiva do sono em crianças. OBJETIVO: Avaliar o impacto da adenoamigdalectomia na qualidade de vida em crianças com hiperplasia adenoamigdaliana. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Trinta e seis pais ou responsáveis de crianças submetidas a adenoamigdalectomia foram entrevistados antes e após a cirurgia através do questionário sobre qualidade de vida específica desenvolvido por Serres et al., 2000, que inclui os domínios: sofrimento físico, distúrbios do sono, problemas de fala e deglutição, desconforto emocional, limitação das atividades e preocupação do responsável. RESULTADOS: A qualidade de vida de todas as crianças melhorou após a cirurgia. Foi observada correlação direta entre o grau de obstrução e distúrbios do sono, preocupação paterna, e na média dos domínios. Correlacionando-se os domínios entre si, observamos relação estatística entre sofrimento emocional e distúrbios do sono, preocupação paterna e distúrbios do sono, limitação das atividades físicas e desconforto emocional. CONCLUSÃO: O aumento das tonsilas e a apnéia obstrutiva do sono pioram a qualidade de vida das crianças, principalmente pelo sofrimento físico e distúrbios do sono. A adenoamigdalectomia realmente traz uma melhora importante na qualidade de vida destes pacientes.

síndrome da apnéia obstrutiva do sono; adenoamigdalectomia; qualidade de vida

ORIGINAL ARTICLE

Improvement in the quality of life of children after adenotonsillectomy

Renata C. Di Francesco^I; Felipe S. G. Fortes^II; Clarissa L. Komatsu^II

^IPh.D. in Medicine, FMUSP. Assistant Physician, Division of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of Sao Paulo

^IIResident Physician, Division of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of Sao Paulo

^{Correspondence}

SUMMARY

Enlarged palatine and pharyngeal tonsils is one of the most frequent occurrences in otorhinolaryngology, and it is the main cause of obstructive sleep apnea in children.

AIM: To evaluate the impact of adenotonsillectomy in the quality of life of children with adenotonsillar hyperplasia.

STUDY DESIGN: Clinical prospective.

MATERIAL AND METHOD: 36 parents/guardians of children who underwent adenotonsillectomy were interviewed, before and after surgery. We used a special Questionnaire about quality of life (developed by Serres' et al. 2000), whose items included physical distress, sleep disorders, speech and swallowing disorders, emotional distress, limitation in activities and parent's/guardian's concern.

RESULTS: The quality of life of all children improved after surgery. There was direct association between the level of airway obstruction and sleep disorders, parent's/guardian's concern and average scores. Comparing the items, we found statistical association between emotional distress and sleep disorders; parent's/guardian's concern and sleep disorders and limitation in activities and emotional distress.

CONCLUSION: Enlarged tonsils and obstructive sleep apnea worsen the quality of life of children, especially because of physical distress and sleep disorders. Adenotonsillectomy greatly improves the quality of life of these patients.

Key words: obstructive sleep apnea, adenotonsillectomy, quality of life.

INTRODUCTION

Enlarged palatine and pharyngeal tonsils is one of the most frequent occurrences in otorhinolaryngology. It is the main cause of obstructive sleep apnea in children, accounting for about 75% of the cases¹. Tonsil removal (adenotonsillectomy) is the treatment of choice², today it is the most common surgery performed by otorhinolaryngologists in the USA³.

Enlarged tonsils and resulting airway obstruction may cause orthognathic dysfunction, chewing and swallowing difficulties and dental arch abnormalities^4,5. Other important consequences are associated with developmental abnormalities, behavioral disorders, poor school performance and cor pulmonale ^6,7. Although the indications for adenotonsillectomy are well established, there are few studies about the impact of surgery in the quality of life of patients⁸. "Quality of life," an expression used since the 90's, is used to evaluate the impact of diseases⁹ on the patients' life.

The main purpose of this study was to compare scores of the Questionnaire about the quality of life of children with enlarged tonsils before and after adenotonsillectomy.

MATERIAL AND METHOD

We interviewed 36 parents/guardian of children who underwent adenotonsillectomy to treat obstructive sleep disorders resulting from enlarged palatine and pharyngeal tonsils. We used a special questionnaire (based on the study from Serres' et al, 2000⁸) to evaluate the patients (Figure 1).

We included in the study patients aged 2 to 15 years, whose pharyngeal tonsils affected over 75% of the rhinopharynx (based on paranasal sinuses radiographic findings) and who also presented enlarged palatine tonsils (grade II or higher)⁷. Children presenting craniofacial abnormalities and neurological disorders were excluded from this study, as well as those patients referred to surgery to treat recurrent tonsillitis.

Parents/guardians answered the Questionnaire based on history 2 months before and 1 month after surgery. The Questionnaires were not applied by the same team who performed surgery.

RESULTS

We evaluated 36 patients, ranging from 2 to 15 years old (average 6.58 years), 14 girls and 22 boys.

Table 1 shows the average score for each item of the Questionnaire, before and after surgery. We distributed the patients into two groups according to their age (2 to 7 and 7 to 15 years old); there was no statistically significant difference between groups. All children improved after surgery. Two patients who showed less improvement after surgery (5%) also had associated rhinitis.

Comparing the level of obstruction caused by pharyngeal and palatine tonsils, we found direct and statistically significant difference between the level of obstruction and sleep disorders, parent's/guardian's concern and general average of items of the Questionnaire (Table 2).

Comparing the items, we found positive association between physical distress and sleep disorders, mother's concern and sleep disorders and limitation of activities and emotional distress (Table 3).

DISCUSSION

Generally, the greatest concern of any disease refers to its physical consequences. However, the impact of a disease on the quality of life of a patient, or his parent/guardian, should also be taken into account when choosing treatment approaches.

Adenotonsillectomy is one of the most common surgeries performed in children³. Although we still do not know all consequences of adenoid and tonsil enlargement, we believe that obstructive sleep apnea accounts for the highest morbidity¹. Other consequences, described as minor ones, include weight and height developmental disorders, craniofacial problems resulting from mouth breathing, chewing and swallowing difficulties and high susceptibility to upper airway infections^4-6. The disease's high morbidity and its impact over the patient's life should be considered when choosing the best treatment approach.

Quality of life has been recently used to evaluate the impact of a disease under the patient's perspective. The Questionnaire used in this study is based on Serres' study⁸, validated for children presenting obstructive sleep disorders. This Questionnaire was used to evaluate the impact of a disease on the patient, in an attempt to include this item and address its severity and importance when evaluating children with enlarged tonsils⁸. The Questionnaire used in this study is a special tool to evaluate the impact of adenotonsillectomy on the quality of life of patients.

We found poor association between level of upper airway obstruction and its impact on quality of life of patients, corroborating Serres's findings¹⁰. However, when we evaluate each item separately, we note that sleep disorders and physical distress are directly proportional to the level of obstruction. Emotional stress, limitation of physical activities and patient's/guardian's concern do not correlate to the degree of obstruction.

Emotional stress and limitation of physical activity did not show low score, as we expected; parent's/guardian's concern was more associated with physical disorders. Other studies found different results for parent's/guardian's concern and the concept of health¹¹, probably related to cultural differences.

Speech and swallowing disorders are common in patients presenting upper airway obstruction⁴, although they did not have a comparative high score. Possibly, it shows that parents/guardians give greater importance to sleep disorders and physical distress, because they were considered to pose great risk for one's health, or because they were not associated with the problem. When we compared such scores after surgery, we noted that they were higher.

There was no difference in scores considering age of the patients. This finding showed us that parent's/guardian's perspective is the same for patients between 2 and 15 years old.

After surgery, there was significant improvement on score averages for all items, proving the success of the surgery to improve the quality of life of the patients. The improvement was greater in items related to physical distress and sleep disorders.

Children presenting rhinitis associated with enlarged palatine and pharyngeal tonsils (5%) had mild improvement on scores. This finding is similar to Serres'¹⁰, who noted 6% mild improvement.

Our results, as well as other authors' results,¹⁰ suggest that adenotonsillectomy presents greater benefit to children with obstructive sleep disorders.

CONCLUSION

We concluded that enlarged pharyngeal and palatine tonsils and obstructive sleep apnea negatively affect the quality of life of children, especially due to the physical distress and sleep disorders resulting from them. After surgery, there is great improvement in quality of life of patients.

REFERENCES

Article submited on August 25, 2004.

Article accepted on November 10, 2004.

Study presented at III Congresso Triológico, Rio de Janeiro, October 8 - 11, 2003, and at 107th Annual Meeting AAO-HNS Foundation – Otolaryngology Head and Neck Surgery, Orlando, USA, in September 2003.

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Publication Dates

• Publication in this collection
  19 Apr 2005
• Date of issue
  Dec 2004

History

• Accepted
  10 Nov 2004
• Received
  25 Aug 2004