A recent study conducted at Long Island College Hospital in Brooklyn, New York, suggests that there is a significant improvement in social and thought problems, attention and sleep problems, as well as delinquent, aggressive and destructive behavior for children who undergo tonsillectomy and adenoidectomies (T&As).
One of the most common surgical procedures performed on children is the T&A. Certainly, no discussion of its risks and benefits would be complete without an overview of the tonsils and adenoids and why we have or need them. Both tonsils and adenoids are known as lymph tissue or glands. They are among hundreds of chains of lymph glands in the body, and happen to reside in the throat and nasal passageway, respectively. Lymph tissue and glands are responsible for filtering blood in order to survey it for foreign invaders, like infectious organisms or tumors. The glands, which are masses of lymph tissue, are interconnected by an extensive pathway of lymphatic channels. The channels carry a fluid, known as lymph, which is a filtrate of blood, throughout the body. When lymphatic fluid reaches a gland, the gland further filters it in order to identify and sequester pathogens that may be present regionally. For instance, the adenoids filter lymphatic fluid from the head and face. When the offending agents become trapped within the glands, the lymphatic channels can now send white blood cells to attack the foreign invader and purge the system. Therefore, an inflammatory assault occurs within the lymph glands, which often results in swollen and tender or painful glands. Many times, most of the selling and inflammation will reside with the resolution of the infection; however, for many people, especially those whom suffer from chronic infections and/or allergies, the glands are chronically swollen and enlarged. They may even become sources of chronic infection, as the colonization of bacteria there may become chronic and on-going. If this happens within the confines of the tonsils and/or adenoids, the person may suffer chronic tonsillitis (inflammation of the tonsils) or adenoiditis (inflammation of the adenoids). Symptoms may include recurrent infection, pain and fever. Further, due to the location of these particular glands, their enlarged state can greatly impact the flow of oxygen past the naso- and oro-pharynges and into the lungs. In many cases like this, due to the chronically sub-optimal levels of oxygen, the person may sleep poorly, and suffer from chronic fatigue. In the most severe cases, the patient will suffer from sleep apnea, where breathing actually ceases for several seconds, but then spontaneously restarts when the brain senses rising levels of carbon dioxide in the blood. This is characterized by very loud and disruptive snoring. Further, patients will often complain of never feeling rested, regardless of time spent asleep.
In children, the significance of this is that their sleep deprivation may easily manifest itself as a behavioral disorder, aggression problem or attention disorder. Further, it is a difficult diagnosis to make unless someone witnesses apneic episodes.
Presently, indications for T&As include: chronic severe tonsillitis/adenoiditis with severe infection requiring admission; in ability to breathe or swallow properly due to glandular enlargement; severe sleep apnea related to enlarged glands. Many providers are reluctant to perform T&As due only to chronic infection or inflammation, as the concern is that removal of this lymph tissue may leave the patient vulnerable to more frequent infections.
In this study, over a 15 month period of time, 64 children, ages 2-18, were studied. They were all children whom had been diagnosed with Obstructive Sleep Apnea and were undergoing a T&A for it. Most families were middle to upper income, with household incomes ranging from $21,000 to $100,000. Children with any anomalies or defects of the face and/or airways were excluded. The male: female ration was 1:3:1. Since different socioeconomic factors can affect behavior, the authors controlled for parental education, income and gender.
The study population showed that 25% of participants had a high prevalence of behavioral and emotional problems After surgery, scores for overall problems, as well as individual domains significantly improved. Post-operatively, only 8% of children scored in an abnormal range for total problems. Further, the prevalence of sleep-disordered breathing also significantly improved, going from 66% to 2%.
This study is very limited due to size, as well as the fact that there was no control group with which to compare the study group. As the authors fully admit, more information is needed in order to understand the true correlation between sleep disorders and behavior in children.
However, this is the first study of its kind to look prospectively at the association between pediatric sleep apnea and behavioral disturbances. While we do not understand the exact pathologic mechanism, for children with obstructive sleep apnea due to chronic tonsillitis/adenoiditis and behavioral or attention problems, we might consider a lower threshold for surgery, in an attempt to relieve the sleep-disordered breathing, and hopefully, the behavioral concerns.