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• W1603611712 abstract "The most common cause of pediatric obstructive sleep apnea (OSA) is adenotonsillar hypertrophy. As such, palatine tonsillectomy with or without adenoidectomy is the first-line treatment for OSA, which can significantly improve the sleep and behavioral disturbances associated with OSA in the majority of patients. However, even after adenotonsillectomy, a reported 20% to 40% of patients have persistent OSA as measured by polysomnography.1 A general consensus among pediatric sleep specialists defines pediatric OSA based on polysomnography parameters of an apnea-hypopnea index (AHI) >1 per hour, a pulse oximetry level <92%, or both. One recognized site of obstruction contributing to some instances of refractory OSA after adenotonsillectomy is lingual tonsil hypertrophy. The diagnosis and treatment of lingual tonsil hypertrophy has been relatively challenging due to limited assessment of the pediatric airway on routine physical exam and to varied surgical techniques. This article explores whether lingual tonsillectomy can improve OSA as evaluated by polysomnography. As part of Waldeyer's ring of lymphoid tissues, lingual tonsil hypertrophy can be found in both healthy patients and in those with medical comorbidities such as obesity, Down syndrome, velocardiofacial syndrome, Beckwith-Widemann syndrome, and other craniofacial anomalies. Obesity and Down syndrome have been identified as risk factors for adenotonsillectomy failure, with undiagnosed lingual tonsil hypertrophy as a possible cause for failure in these populations.1, 2 The diagnostic tools used to detect lingual tonsil hypertrophy are variable based on examination conducted during either the awake or sleep state. Office-based flexible fiberoptic endoscopy allows for a quick and initial evaluation in the awake patient. Computed tomography (CT) and magnetic resonance imaging (MRI), with or without dynamic cine, can also provide accurate assessment of upper airway obstruction but may be less cost-effective. More recently, drug-induced sleep endoscopy performed in the operating room under spontaneous bag-mask ventilation and intravenous propofol or dexmedetomidine infusion has been proposed as a new strategy to directly visualize the site of dynamic airway collapse in an environment simulating natural sleep.2 After identifying the site of obstruction, the surgeon has the opportunity to immediately perform sleep endoscopy-directed surgery to relieve the obstruction. There is no described single, best surgical technique for resecting lingual tonsil tissue. Various methods have been explored, including laser, microdebrider, suction electrocautery, and bipolar radiofrequency. Lingual tonsillectomy can be performed either transorally by tongue base delivery and direct excision or by suspension and endoscopic excision. Debulking occurs from the circumvallate papilla to the vallecula until the epiglottis is easily visualized. Patients are typically admitted for overnight observation. Lin and Koltai examined the pre- and postoperative polysomnography data of 26 patients with persistent OSA after adenotonsillectomy, who then underwent endoscopic-assisted radiofrequency lingual tonsillectomy. Postoperative sleep studies obtained at a mean of 4 months demonstrated a statistically significant reduction in the respiratory distress index (RDI) and obstructive apneas. The mean preoperative RDI decreased from 14.7 to 8.1 postoperatively. The mean obstructive apneas diminished from 18.1 to 2.2. There was also a downward trend seen in obstructive hypopneas; however, this was not statistically significant. Minimum oxygen saturation also did not change significantly.3 Abdel-Aziz et al. performed lingual tonsillectomy on 16 patients with unipolar diathermy under direct visualization. Diagnosis of lingual tonsillar hypertrophy was confirmed using CT in 10 cases, MRI in three cases, and both in three cases. Flexible fiberoptic laryngoscopy was also performed in the clinic to detect the site of obstruction at the lingual tonsils. The study reported a postoperative improvement in mean apneas (16.7 to 1.9), hypopneas (42.2 to 25.8), AHI (10.5 to 3.2), and minimal oxygen saturation (84% to 91%). Statistical analysis was not conducted. In two patients, polysomnography data demonstrated an interval improvement from moderate to mild OSA after surgery. One patient had Down syndrome and the other had mucopolysaccharidoses.4 Truong et al. used drug-induced sleep endoscopy to identify lingual tonsillar hypertrophy as the most common source of persistent OSA after adenotonsillectomy. Among a cohort of 41 children with failed adenotonsillectomy who underwent sleep endoscopy, 27 patients received lingual tonsillectomy, which decreased the mean AHI from 18.3 to 9.7 (P < .05).2 As the above literature review indicates, lingual tonsillectomy cannot definitively cure persistent OSA. Although polysomnography parameters improve after lingual tonsillectomy, they often remain abnormal. Chan et al. attempted to identify reasons for suboptimal cure rates in lingual tonsillectomy. Their study revealed that overweight children who underwent endoscopic-assisted coblation lingual tonsillectomy had significantly worse sleep outcomes than children of normal weight who underwent lingual tonsillectomy. Overweight children, defined as >85th percentile body mass index for age, also tended to have an overall higher postoperative AHI. However, patients with comorbidities such as Down syndrome, hypotonia, neuromuscular dysfunction, cerebral palsy, and severe asthma had similar post-lingual tonsillectomy polysomnography outcomes as those without comorbidities.5 In cases of pediatric OSA refractory to adenotonsillectomy, practitioners should consider lingual tonsil hypertrophy as a potential obstructive phenomenon. Diagnostic and surgical treatment modalities for lingual tonsil hypertrophy vary depending on patient cooperation, available resources, and surgeon preference. Despite the paucity of available literature, current evidence suggests that lingual tonsillectomy is beneficial in improving the sleep parameters of RDI, AHI, and obstructive apneas in the pediatric population. Additionally, a significant limitation in all of the above-cited studies is the absence of a control group of children who did not undergo lingual tonsillectomy. Being overweight may also be a risk factor that reduces the likelihood of successful surgical intervention. This review of the benefits of pediatric lingual tonsillectomy for persistent OSA after adenotonsillectomy is based on level II studies." @default.
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• W1603611712 date "2014-03-01" @default.
• W1603611712 modified "2023-10-16" @default.
• W1603611712 title "Can lingual tonsillectomy improve persistent pediatric obstructive sleep apnea?" @default.
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