Effects of Adenotonsillectomy on Children with Asthma
 
Study Description:

A retrospective review of patients that underwent adenoidectomy and/or tonsillectomy within the last 5 years and carried a diagnosis of asthma. These charts were reviewed to glean demographic information on the patient in order to conduct caregiver interviews. Eighty seven charts were identified for review, and 38 interviews were completed. The remaining patients were unable to be contacted or excluded for co-morbidities that would impact disease (i.e. cystic fibrosis, immotile cilia syndrome, subglottic stenosis etc).

Patients were included in the study if they had undergone adenoidectomy and/or tonsillectomy within the last five years, and carried a diagnosis of asthma without a significant co-morbidity. Indications for surgery included obstructive sleep apnea, chronic tonsillitis, chronic sinusitis, or other related disorders. Both cold-knife and electrocautery techniques of tonsillectomy were included and adenoidectomies performed by both curettage and cautery were included. Asthma was diagnosed by a primary care physician or a pediatric pulmonologist. Exclusion criteria included co-morbidities such as cystic fibrosis, immunologic deficiencies, severe gastroesophageal reflux.

Methodology:

A phone questionnaire or personal interview was designed for caregivers to assess pre and post operative signs and symptoms of asthma in the patient. The parent was asked to answer the same set of questions before surgery and after surgery. The survey was given no less than six months after surgery and no more than five years after surgery.

Yes or no questions were asked about the use of the following medications: systemic steroids, inhaled steroids, Albuterol, long acting beta₂-agonists and leukotriene moderators. We also asked how many courses per year of systemic steroids the patient used. The severity of asthma as judged by primary caregivers was assessed to be: “none,” “mild intermittent,” “mild persistent,” “moderate persistent,” or “severe persistent.” The , number of missed school days/year and number of missed work days/year for parents were all quantified.. Any other current diagnosis was included to determine co-morbidity.

Results:

The mean age of the 38 patients included in the study was 5.4 years, ranging from 2 to 12 years at the time of surgery. 14 patients (36%) were younger than 5 years, and 24 patients (63%) were 5 years or older. The male to female ratio was 1.92 (25 males, 13 females). The mean post operative follow up period was 1.5 years, ranging from 7 month to 4 years. 8 patients (21%) underwent adenoidectomy alone, and 30 patients (79%) underwent adenotonsillectomy.

Patients underwent surgery for obstructive sleep apnea (23 patients, 60%), chronic tonsillitis (6 patients, 16%), and “other reasons,” which included asymmetric palatine tonsillar hypertrophy, chronic halitosis, or chronic sinusitis (9 patients, 24%).

Medication Use:

Medication use dropped greatly after surgery. Of the 26 children using inhaled steroids before surgery, 17 reported using them after surgery (34.6% reduction). None of the 11 children who were not on inhaled steroids before surgery started using them after. Overall, there were significantly fewer children on inhaled steroids after surgery than before (X² (1) = 13.31, p=.001). Of the 33 children using albuterol before surgery,18 reported continued use after surgery (45.4% reduction). None of the 33 children not using albuterol before surgery started using it after. Although a 45% reduction in albuterol use is certainly clinically significant, the small sample size of children not using it before surgery yields a non-statistically significant result (X²(1)=3.27,p>.05)

Regarding long-acting beta 2 agonist use prior to surgery, 4 of 31 children reported long-acting beta 2 agonist use. Following surgery, these children discontinued use and no children in the sample reported use of long-acting beta 2 agonists. Because long-acting beta 2 agonist use was a constant after surgery (i.e. no children using this medication), chi-square analyses could not be conducted. Of the 19 children using Leukotriene moderators before surgery, only 10 continued to use them after surgery (47.4% reduction). None of the 17 children not using Leukotriene moderators before surgery began using them after surgery. Overall, significantly less children used Leukotriene moderators before surgery than after (X²(1)=12.39, p=.001).

12 patients (31%) to 11 patients (28%).

Concerning systemic oral steroid use, of the 18 children using systemic oral steroids before surgery, only 6 reported using them after surgery (66.6% reduction). One of the 17 children not using steroids before surgery started using them after surgery. Overall there were significantly less children on systemic oral steroids following surgery than before(X²(1) = 4.12, p =.04).

Before surgery, 19 patients (50%) had used systemic steroids at least once per year. Three required one course, 6 required two courses, 3 required three courses, 1 required four courses, and 5 patients required five or more courses/year. After surgery, only 7 patients (18%) used systemic steroids, and the number of courses/year decreased. Four patients required one course, 2 patients required two courses, and no patients needed three or more courses/year (Figure 2).

Asthma severity:

A decrease in severity of asthma was also observed. Chi-square analyses indicated a significant change in the distribution of asthma severity scores from pre- to post surgery (X²(16) = 28.30, p =.02). Notably, 16 children who carried a diagnosis of asthma before surgery ceased to carry this diagnosis following surgery. Of those children who continued to carry a diagnosis of asthma, 8 children (38.1%) decreased by one classification (e.g. from severe persistent to moderate persistent, from mild persistent to mild intermittent). Six children (28.6%) showed a decrease of 2 classifications ( all from moderate persistent to mild intermittent), and 3 children (14.3%) showed a decrease of 3 classifications (all from severe persistent to mild intermittent). Four children remained the same asthma classification following surgery as they had before (3 at mild intermittent, 1 at severe persistent). The average asthma severity score decreased from 2.12 preoperatively to 0.74 postoperatively.

School Attendance:

Of the 29 children who attended school, chi square analyses indicated significant change in the distribution of number of school days missed (X²(35) = 54.38, p =.02). Prior to surgery, only one child was reported to have missed no days of school. Following surgery, 8 additional children (9 total) were reported to have missed no school days. Four children (13.8%) maintained their level of school absences and 7 children (24.1%) decreased by one level of absence (e.g. from 4-6 days to 1-3 days, from 7-10 days to 4-6 days). Ten children (34.5%) decreased by two levels of absence ( e.g. from 7-10 days to 1-3 days), two children (6.9%) decreased by three levels, and three (10.3%) decreased by four or more levels. The average number of missed school days/year decreased from 7.76 to 3.28. The average number of missed work days/year for working parents decreased from 7.35 to 1.8.

Conclusions:

Adenotonsillectomy performed for patients who have a separate indication for the procedure (i.e. OSA, chronic tonsillitis, etc) appear to have significant improvement in the clinical status of their asthma. (Karas, 2005)