The impact of adenotonsillectomy on healthcare utilization in children with obstructive sleep apnea: Experience of an integrated medical model.

BACKGROUND AND OBJECTIVES: Studies suggest that children with obstructive sleep apnea (OSA) have increased healthcare utilization patterns in comparison to matched controls. However, the effect of adenotonsillectomy (AT) on utilization patterns in these children is poorly understood. Additionally, no previous studies have compared the effect of AT on healthcare utilization patterns across different OSA severity groups. The aim of this retrospective cohort study is to assess the effects of surgical treatment on the level of healthcare utilization among children with OSA at a large integrated multicenter healthcare system. METHODS: Retrospective analysis was performed of children aged 3-12 diagnosed with OSA via an attended polysomnogram (PSG) between December 2016 and February 2019. Demographic variables including age (at time of PSG), body mass index (BMI), race, and ethnicity were obtained. Variables for healthcare utilization were assessed for 12 months prior to PSG, and for 12 months after PSG (or after AT, delayed for the first 30 days after surgery to account for surgery-related visits). Healthcare utilization variables assessed included the total number of outpatient visits, inpatient, and emergency department (ED) visits, visits involving diagnostic codes associated with upper respiratory infection (URI), otitis media (OM), and allergic rhinitis (AR), prescription data involving intranasal steroids or leukotriene receptor antagonists (LTRA), and communication data such as secure message load and specialty referrals. Repeated measure linear difference-in-difference (D-I-D) models were used to assess the causal impact of AT on healthcare utilization outcomes. Sensitivity analyses were performed using modeling with a Poisson distribution and as an unadjusted model, with statistical significance set to p < 0.05. RESULTS: Analysis elicited 577 children identified with OSA. Of these, 336 (58.2 %) underwent observation while 241 (41.8 %) underwent AT. The mean age was 6.4 years, with a slight male predominance (60.5 %). Analysis of baseline healthcare utilization patterns revealed that the treatment group had a significantly higher number of baseline inpatient/ED visits and OM visits in comparison to the observation group, but no differences in regards to baseline outpatient visits, or in visits involving URI or AR. Analysis of the entire OSA cohort via D-I-D modelling showed a significantly larger reduction in outpatient visits, secure messages, specialty referrals, and the use of intranasal steroid and LTRA in the treatment group compared to the observation group. Stratification of children based on OSA severity showed that the significant differences in healthcare utilization attributed to surgical treatment were primarily driven by the severe OSA group. Children with severe OSA who underwent AT showed significant reductions in most variables including outpatient visits, inpatient/ED visits, and OM visits. Alternatively, the only significant reductions in healthcare utilization among children with mild OSA treated with AT were in AR visits, intranasal steroid use, and LTRA use. Pattern changes among children with moderate OSA compared similarly to those with mild OSA. CONCLUSION: To the authors' knowledge this study represents the largest available study assessing the impact of AT on healthcare utilization in children with OSA that also considers the effect of OSA severity on utilization patterns. AT appears to decrease healthcare utilization patterns, particularly in children with severe OSA. Alternatively, children with mild or moderate OSA treated with AT had only modest reductions in healthcare utilization patterns.

Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Sociodemographic associations of geographic variation in paediatric tonsillectomy and adenoidectomy.

Geographic variation of paediatric tonsillectomy, with or without adenoidectomy, (A/T) has been described since the 1930s until today but no studies have investigated the factors associated with this variation. This study described the geographical distribution of paediatric A/T across the state of Victoria, Australia, and investigated area-level factors associated with this variation. We used linked administrative datasets capturing all paediatric A/T performed between 2010 and 2015 in Victoria. Surgery data were collapsed by patient residence to the level of Local Government Area. Regression models were used to investigate the association between likelihood of surgery and area-level factors. We found a 10.2-fold difference in A/T rates across the state, with areas of higher rates more in regional than metropolitan areas. Area-level factors associated with geographic variation of A/T were percentage of children aged 5-9 years (IRR 1.07, 95%CI 1.01-1.14, P = 0.03) and low English language proficiency (IRR 0.95, 95% CI 0.90-0.99, P = 0.03). In a sub-population analysis of surgeries in the public sector, these factors were low maternal educational attainment (IRR 1.09, 95% CI 1.02-1.16, P < 0.001) and surgical waiting time (IRR 0.99635 95% CI 0.99273-0.99997, P = 0.048). Identifying areas of focus for improvement and factors associated with geographic variation will assist in improving equitable provision of paediatric A/T and decrease variability within regions.

Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines.

OBJECTIVE: Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS: A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS: Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2  = 0.38 P = .003). CONCLUSIONS: Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2610-2615, 2021.

Cardiopulmonary Testing before Pediatric Adenotonsillectomy for Severe and Very Severe Obstructive Sleep Apnea Syndrome.

OBJECTIVES/HYPOTHESIS: Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). RESULTS: Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). CONCLUSIONS: Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2361-2368, 2021.

Risk Factors for Multiple Tympanostomy Tube Placements in Children: Systematic Review and Meta-Analysis.

OBJECTIVES/HYPOTHESIS: To determine the rate and predictors of receiving multiple tympanostomy tube (TT) placements in children. STUDY DESIGN: Systematic review and meta-analysis. METHODS: PubMed, EMBASE, and Cochrane Library databases were searched for studies reporting the risk factors for receiving repeat TT (r-TT) placements in children with chronic otitis media with effusion or recurrent acute otitis media. These articles were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Data were pooled using a random-effects model. RESULTS: Twenty-one studies involving a total of 290,897 children were included. Among all patients, 24.1% (95% confidence interval (CI), 18.2%-29.9%) underwent ≥2 TT placements and 7.5% (95% CI, 5.7%-9.4%) underwent ≥3 TT placements. Craniofacial disease (odds ratio (OR) 5.13, 95% CI, 1.57-16.74) was the strongest predictor of r-TT. Younger age at initial TT placement and shorter TT retention time were also significantly associated with r-TT. Receipt of primary adenoidectomy with initial TT placement was associated with decreased odds of r-TT (OR, 0.46; 95% CI, 0.39-0.55). Long-term tubes also significantly reduced the odds of r-TT (OR, 0.27; 95% CI, 0.17-0.44). CONCLUSIONS: About 1 in 4 children receiving TT will receive at least one repeat set of TT and about 1 in 14 will receive multiple repeat sets. Concurrent adenoidectomy and long-term tubes reduced the incidence of r-TT. Younger patients and those with earlier extrusion of the initial set are at increased risk for repeat surgery. The identification of these risk factors may improve parental counseling and identify patients who might benefit from closer follow-up. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2363-E2370, 2021.

The Effect of Tonsillectomy and Adenoidectomy on Isolated Sleep Associated Hypoventilation in Children.

OBJECTIVE: Sleep associated hypoventilation (SAH) is diagnosed when more than 25% of total sleep time (%TST) is spent with end tidal carbon dioxide (EtCO2 ) > 50 mmHg. SAH in children occurs as a single entity or combined with obstructive sleep apnea. Outcomes of surgical treatment for isolated SAH in children have not been reported. METHODS: The medical charts of children who were diagnosed with isolated SAH and did not have OSA at a tertiary children's hospital between January 2013 and December 2019 were reviewed. Data collection included information on history and physical examination, past medical history, polysomnography (PSG) findings, and surgical management. RESULTS: Seventeen children (10 male, 7 female, age range: 3-14 years) were diagnosed with isolated SAH. Comorbid conditions included asthma in four children, Down syndrome in one, and seizure in two. Eight children were normal weight, four were overweight, and five were obese. Children did not have obstructive or central sleep apnea. Three children (18%) had persistent SAH as documented by PSG. All normal weight children had resolution of SAH whereas two obese children and one overweight child had residual SAH. %TST with CO2 > 50 mmHg after upper airway surgery (3.4% ± 1.6%) was significantly less than that of before TA (59.1% ± 5.5%) (P < .001). CONCLUSIONS: The majority of children with isolated SAH had normalization of hypercapnia after TA. Further studies in larger groups of children are needed to identify the risk factors for residual isolated SAH after TA. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1380-E1382, 2021.

Changes in healthcare utilisation for paediatric tonsillectomy and adenoidectomy in the Netherlands: a population-based study.

OBJECTIVES: Tonsillectomy and adenoidectomy in children are controversial subjects with large regional variation in surgical rates, partly explained by cultural differences and lack of high-quality evidence on indications for surgery. A quality of care cycle was executed on this topic in the Netherlands. The objective of this study was to estimate changes in healthcare utilisation for paediatric tonsil surgery in the Netherlands. METHODS: Population-based data on tonsillectomies and adenoidectomies in children up to age 10 were retrieved retrospectively from Dutch administrative databases between 2005 and 2018. A change point analysis was performed to detect the most pivotal change point in surgical rates. We performed univariate analyses to compare surgical patients' characteristics before and after the pivotalpoint . Impact on healthcare budget and societal costs were estimated using current prices and data from cost-effectiveness analyses. RESULTS: The annual number of adenotonsillectomies reduced by 10 952 procedures (-39%; from 129 per 10 000 children to 87 per 10 000 children) between 2005 and 2018, and the number of adenoidectomies by 14 757 procedures (-49%; from 138 per 10 000 children to 78 per 10 000 children). The most pivotal change point was observed around 2012, accompanied by small changes in patient selection for surgery before and after 2012. An estimated €5.3 million per year was saved on the healthcare budget and €10.4 million per year on societal costs. CONCLUSION: The quality of care cycle resulted in fewer operations, with a concomitant reduction of costs. We suggest that part of these savings be invested in new research to maintain the quality of care cycle.

Long-term Impact of Middle Ear Effusion in Pediatric Tympanostomy Tubes.

OBJECTIVES/HYPOTHESIS: Bilateral myringotomy and tympanostomy tube placement (BMT) is the most common pediatric surgery in the United States. Intraoperative middle ear effusion (MEE) is a risk factor for future BMTs in children with recurrent acute otitis media (RAOM). However, the impact of the type of MEE is unknown. Here, we assess otologic outcomes based on intraoperative MEE type and indication for surgery. STUDY DESIGN: Case series chart review. METHODS: After institutional review board approval, we performed a review of children undergoing BMTs between 2008 and 2009. Included patients had their first BMT, preoperative visit, and an operative report. Patients with cleft palate or Down syndrome were excluded. Indications for surgery included RAOM and chronic otitis media with effusion (COME). Other variables evaluated were future BMT, acquired cholesteatoma, and otorrhea. Logistic regression was used for statistical analysis. RESULTS: Out of 1,045 patients reviewed, 680 were included and underwent their first BMT. There were 619 patients who had RAOM. Serous effusions were present in 22.2%, mucoid in 31.3%, purulent in 12.9%, undocumented or bloody in 2.3% of patients, and 31.2% of patients had dry middle ears. Moreover, 22.7% of patients underwent future BMTs. In RAOM patients, serous effusions decreased odds of perforation (odds ratio [OR]: 0.195, 95% confidence interval [CI]: 0.0438-0.867, P = .032), and purulent effusions increased the odds of in-office otorrhea suctioning (OR: 2.13, 95% CI: 1.20-3.77, P = .010) compared to dry. Mucoid effusions had no significant effect on outcomes in COME or RAOM patients. CONCLUSIONS: Intraoperative MEEs were noted in 68.7% of cases; purulent effusions increase the odds of in-office suctioning in RAOM patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E993-E997, 2021.

Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy.

Importance: Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. Objective: To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. Design, Setting, and Participants: Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. Main Outcomes and Measures: Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. Results: A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. Conclusions and Relevance: Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.

Cost-effectiveness of polysomnography in the management of pediatric obstructive sleep apnea.

OBJECTIVES: At our institution, younger children require polysomnography (PSG) testing to confirm obstructive sleep apnea (OSA hereafter) before surgical intervention by adenotonsillectomy (T&A). Given that sleep studies can be costly, we investigated the cost-effectiveness of PSG as well as the possible role for symptom documentation in evaluation for T&A. METHODS: Pediatric patients age 1-3 years who received PSG testing between Jan. 2015 and Jan. 2016 who had not previously had T&A were identified for retrospective cost analysis. Cost data were obtained from institutional accountants. We defined a positive PSG as obstructive apnea-hypopnea index ≥1. Logistic regression analysis was used, and statistical significance was set a priori at p < 0.05. Sensitivities and specificities of symptom documentation screen for OSA were compared to gold standard, or PSG testing. RESULTS: Of the 176 children who received polysomnography testing, 140 (80%) had a positive PSG indicative of OSA. Seventy-one (51%) children with OSA underwent T&A within 1 year of PSG, and 10 (7%) eventually received T&A after 1 year from PSG date. Of the children whose PSG results were negative (n = 36), 14 (39%) still underwent T&A within 1 year (n = 7, 19%) or later (n = 7, 19%). Children with positive sleep studies were significantly more likely to receive T&A within one year of PSG (p = 0.0006) and at any time after PSG (p = 0.04). Hospital costs for T&A varied widely while PSG costs were fairly consistent. Using average institutional costs of T&A and PSG, the total cost of a T&A was 17.7× the cost of PSG testing. Using number of recorded symptoms to diagnose OSA instead of PSG testing yielded low specificities. CONCLUSION: Fifty-eight percent of patients with OSA and 39% of patients without OSA had a T&A within 1 year or later, although positive PSG was significantly associated with a higher likelihood of receiving T&A. Given costs at this institution and current decision-making practices, 147 PSGs would need to be done to account for the cost of one T&A, which in our cohort would occur after approximately 305 days.

Outcomes Assessment of Multi-Level Sleep Surgery in Syndromic Versus Non-Syndromic Children.

OBJECTIVES: Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery. METHODS: Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square. RESULTS: Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P > .05). CONCLUSION: The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Postoperative complications after adenotonsillectomy in two paediatric groups: Obstructive sleep apnoea syndrome and recurrent tonsillitis. / Complicaciones postoperatorias tras adenoamigdalectomía en 2 grupos de pacientes pediátricos: síndrome de apnea-hipopnea del sueño e infecciones de repetición.

INTRODUCTION AND OBJECTIVES: Adenotonsillectomy is a surgery to treat recurrent tonsillitis or obstructive sleep apnoea syndrome (OSAS). It is considered a safe procedure, with few complications. Moreover, patients over 3 years and without comorbidities do not present a higher rate of respiratory adverse events after the immediate postoperative period, and do not need systematic admission to a paediatric intensive care unit (PICU), regardless of their OSAS severity. The aim of this study is to reanalyse the situation, including patients under the age of 3 years, for whom there are fewer available data, to confirm that this trend has not changed. METHODS: A retrospective observational study was performed, including all adenotonsillectomised children in our hospital over 5 years. RESULTS: 418 adenotonsillectomised children were included, 56.7% due to recurrent tonsillitis, and 43.3% because of OSAS. Only 24 patients (5%7%) experienced adverse events, of whom 1.2% had vomiting, 3.1% bleeding, and 1.4% respiratory events. All the respiratory events occurred in the operating theatre or in the post-anaesthetic unit, most frequently in children with severe OSAS, while the tonsillitis group had more bleeding (P=.046). No differences in complications were observed according to age (P=0.174), but the group of patients under three years was relatively small. CONCLUSIONS: No differences were found in the percentage of complications between the two groups. Although the OSAS group exhibited more respiratory events, these occurred in the immediate postoperative period; otherwise, there was a higher risk of bleeding in the tonsillitis group. These results support the findings indicating that routine PICU admission is not required for these patients.

Evaluating pediatric intensive care unit utilization after tonsillectomy.

OBJECTIVES: To identify patients at risk for a pediatric intensive care unit (PICU) level intervention after adenotonsillectomy. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary Children's Hospital. SUBJECTS AND METHODS: Ninety-four patients who were admitted to the PICU after adenotonsillectomy were included. The need for PICU level intervention, defined as high flow oxygen by nasal cannula, positive airway pressure (PAP), heliox, and intubation, was documented. The age, gender, BMI percentile, polysomnography (PSG) data, home PAP use, and accompanying comorbidities of patients who required a PICU level intervention were compared to those who did not. RESULTS: Of the 94 patients admitted post-adenotonsillectomy to the PICU, most had at least one comorbidity, with obesity being the most common. PICU admission was unplanned in 29 (30.9%) patients. Postoperatively, 25 (26.5%) patients required a PICU level intervention, with PAP being the most common intervention. On chi-square analysis, there was no significant difference in the age, BMI percentile, or PSG parameters of children who required PICU intervention. Significantly more children who used preoperative PAP were started on PAP in PICU (p = 0.018). Only the comorbidity of neuromuscular disorder was associated with PICU intervention (p = 0.04). Using binary logistic regression, the use of home PAP and an oxygen nadir <80% on preoperative PSG were found to be independent predictors of PICU intervention (p = 0.04 and 0.025, respectively). CONCLUSION: Home PAP use, the presence of a neuromuscular disorder, and an oxygen nadir <80% on preoperative PSG is related to a PICU level intervention.

No impact on the incidence rate of adenoidectomy 1998-2014 on a national level in Denmark by the use of nasal steroid and the introduction of pneumococcal vaccines.

OBJECTIVE: To describe trends in incidence rates of adenoidectomy in children in Denmark from 1998-2014 and to look for possible explanatory factors such as intranasal steroids and pneumococcal vaccination. DESIGN: A nationwide, population-based, retrospective, interrupted time-series analysis, using data from Danish registries. SETTING: Hospitals and private Ear, Nose and Throat clinics. PARTICIPANTS: Children who underwent adenoidectomy from 1998 to 2014 in Denmark. MAIN OUTCOME MEASURE: Adenoidectomy. METHODS: The National Patient Register and the National Health insurance Service Register were used to identify all adenoidectomies performed in children. The National Prescription Register supplied data on intranasal steroids. RESULTS: A total of 174,557 adenoidectomies were identified, distributed among 153 022 children. The annual incidence rate was stable at around 11 per 1000 person-years from 1998 to 2004. A decrease was seen from 2004 reaching 7.9 in 2009, followed by an increase to 9.1 in 2014. The highest age-specific incidence rates were seen at 2-3 years of age. An estimated 14% of children born in 2014 will have had adenoidectomy performed before turning 16 years old. The proportion of adenoidectomies performed in private clinics compared with hospitals was 90%. CONCLUSION: From 1998 to 2004 the incidence rate of adenoidectomy in children in Denmark was among the highest in the world with around 11 per 1000 person-years. A decrease to 7.9 was seen from 2004 to 2009. We found no inverse correlation on a national level between the incidence rates of adenoidectomy and intranasal steroid, nor the introduction of the pneumococcal vaccine. The amount of intranasal steroids used in children in Denmark was negligible compared with adenoidectomy.

Prevalence and Trends in Obesity Among Hospitalized Children.

OBJECTIVES: As obesity rates rise in children, it is likely that the number of hospitalized children with obesity is also increasing. However, characterization of the inpatient population with obesity as a whole has not been reported. We aimed to examine trends in the annual prevalence of obesity in hospitalized children and to identify demographic and clinical characteristics associated with higher obesity prevalence in children who are hospitalized. METHODS: We completed a retrospective cohort analysis of children aged 2 to 19 years admitted to a single tertiary children's hospital system for any reason in 2009-2016. Body mass index was calculated from documented height and weight. Children with obesity were defined by using age- and sex-specific body mass index percentile guidelines established by the Centers for Disease Control and Prevention. Annual obesity prevalence was calculated on the encounter level for service line and All Patients Refined Diagnosis-Related Groups (diagnosis groups). χ2 tests were used to determine statistical differences between groups, and the Cochran-Armitage test of trend was used to describe changes in obesity over time. RESULTS: Of 83 329 children who were hospitalized, 17.0% had obesity, increasing from 16.5% of hospitalizations in 2009-2010 to 17.3% in 2015-2016 (P = .002). Service lines with the highest obesity prevalence included orthopedics (22.1%), infectious disease (20.6%), and neuroscience (18.7%). Diagnosis groups with the highest obesity prevalence included cellulitis (22.5%), tonsil/adenoid procedures (22.0%), and some orthopedic procedures (28.7%). CONCLUSIONS: Some groups of children who were hospitalized experience higher obesity prevalence, including children hospitalized with orthopedic, infectious disease, and neurologic problems. In future research, investigators should target disproportionately affected groups by examining health outcomes, patient safety, and satisfaction issues.

Risk factors for children requiring adenotonsillectomy and their impact on postoperative complications: a retrospective analysis of 2000 patients.

Adenotonsillectomies are commonly performed procedures and sleep-disordered breathing is becoming increasingly important as an indication for surgery. Because of the higher risks in patients with obstructive sleep apnoea, the required level of postoperative care for these patients is currently under discussion, and better identification of patients at risk may reduce unnecessary postoperative monitoring. To evaluate the influence of obstructive sleep apnoea, and other risk factors, on peri-operative complications in children requiring adenotonsillectomy, we performed a retrospective case-control study that included 1995 patients treated between January 2009 and June 2017. In our analysis, young age (OR 3.8, 95%CI 2.1-7.1), low body weight (OR 2.6, 95%CI 1.5-4.4), obstructive sleep apnoea (OR 2.4, 95%CI 1.5-3.8), pre-existing craniofacial or syndromal disorders (OR 2.3, 95%CI 1.4-3.8) and adenotonsillectomy, compared with adenoidectomy alone, (OR 7.9, 95%CI 4.7-13.1) were identified as risk factors for complications during or after surgery, p < 0.001. All 13 patients suffering from complications more than 3 h postoperatively had obstructive sleep apnoea plus at least one more of these risk factors. Patients at risk of postoperative complications can therefore be identified by several criteria pre-operatively, and should be monitored postoperatively using pulse oximetry overnight. For all other patients, postoperative observation on a surgical ward without extra monitoring is sufficient. Admission to paediatric intensive care should be reserved for patients suffering serious intra-operative complications.

An epidemiological study of paediatric adenotonsillectomy in Victoria, Australia, 2010-2015: Changing indications and lack of effect of hospital volume on inter-hospital transfers.

OBJECTIVE: To describe the contemporary epidemiology of paediatric adenotonsillectomy in an Australian setting, examine the incidence rate over 2010-2015 and investigate factors associated with inter-hospital transfer. DESIGN: Retrospective population-based study. SETTING: Multicentre study in the state of Victoria, Australia. PARTICIPANTS: From the Victorian Admitted Episodes Dataset, which included all patients aged 0-19 years who underwent adenoidectomy and/or tonsillectomy in Victoria, Australia between 2010 and 2015. MAIN OUTCOME MEASURES: Annual incidence rate, hospital volume, inter-hospital transfer. RESULTS: Between 2010 and 2015, 59 008 patients underwent 61 281 procedures, with highest number performed in males (52.7%), children aged under 10 years (73.5%) and in the higher socioeconomic groups (24.6% in quintile 4 and 23.2% in quintile 5). Seventy-five cases (0.12%) resulted in inter-hospital transfer, which was significantly associated with young age (under 5 years). More than a third of hospitals (35.7%) performed an average rate of <1 procedure per week. Hospital volume was not associated with risk of inter-hospital transfer. The incidence rate of adenotonsillectomy procedures significantly increased over the study period (P < .001), driven by a significant increase in the rate of surgery performed for obstructive symptoms (P < .001). CONCLUSIONS: The rate of adenoidectomy/tonsillectomy procedures is rising, with a higher proportion being performed in socioeconomically advantaged patients. This raises concerns regarding healthcare access, given the literature supporting higher rates of obstructive sleep-disordered breathing and sore throat in lower socioeconomic groups. A third of hospitals performed small numbers of procedures, but we found no association between hospital volume and inter-hospital transfers.

Hospital admissions for acute throat and deep neck infections versus tonsillectomy rates in Germany.

PURPOSE: To evaluate trends in hospital admissions in Germany for acute infections of the upper airway and deep neck in the context of the number of tonsil-related surgical procedures between 2005 and 2017. METHODS: A retrospective longitudinal population-based cohort study was performed including all unplanned admissions for acute pharyngitis/tonsillitis, abscess formation of the peritonsillar or retropharyngeal/parapharyngeal space. Elective procedures included tonsillectomy (with or without adenoidectomy), secondary tonsillectomy, and tonsillotomy. Emergency operations encompassed abscess-tonsillectomy and transoral drainage procedures of the peritonsillar/parapharyngeal/retropharyngeal space. RESULTS: 553.600 admissions were registered in total with a significant, stepwise increase between 2005 and 2017, including retropharyngeal/parapharyngeal abscess (47.0%), acute tonsillitis (30.8%), acute pharyngitis (26.5%) and peritonsillar abscess (7.9%). There were 1.323.984 elective operations with a significant decrease during the study period. A total of 188.316 emergency operations were done, a significant decrease in the number of abscess-tonsillectomies was compensated by the increased number of transoral peritonsillar abscess drainages. The number of transoral parapharyngeal and retropharygeal abscess drainage procedures did not change significantly (p = 0.846; p = 0.846). Negative correlation was significant between admissions for chronic tonsillitis and emergency admissions (Pearson correlation coefficient = - 0.879, p < 0.001) and also between elective and emergency operations (r = - 0.667; p = 0.013). CONCLUSIONS: Concerning infections of the upper airway and deep neck spaces, German Hospitals have to prepare strategies for the increasing challenge by unplanned admissions and emergency operations. Further research is required to clarify whether this phenomenon is caused by the significant decrease in the number of elective operations.

A Cross-sectional Analysis of Pediatric Ambulatory Tonsillectomy Surgery in the United States.

OBJECTIVES: To report nationwide estimates of ambulatory tonsillectomies performed in hospitals and ambulatory surgery centers in the United States. STUDY DESIGN: Cross-sectional survey. SETTING: National databases. SUBJECTS AND METHODS: We analyzed the 2010 National Hospital Ambulatory Medical Care Survey of hospitals and ambulatory surgery centers for pediatric patients undergoing tonsillectomy with or without adenoidectomy. We determined estimations of the number of procedures, demographics, and outcomes. A tonsillectomy cohort from the 2009 National Inpatient Sample served as a comparison group. RESULTS: In 2010, there were an estimated 339,000 (95% CI, 288,000-391,000) ambulatory tonsillectomies in the United States. The mean age was 7.8 years (SD, 5.1), and 71,000 (21.0%) were <3 years old. The male:female ratio was even (51% vs 49%). The racial makeup mirrored the US census (69% white, 18% Hispanic, and 12% black). Obstructive sleep-disordered breathing was reported in 48%. Perioperative events such as apnea, hypoxia, or bleeding occurred 7.8% of the time. Approximately 9% of patients could not be discharged home. When compared with cases of inpatient tonsillectomies, ambulatory cases comprised older patients (7.8 vs 5.9 years, P < .001) and were less likely to include obstructive sleep-disordered breathing (48% vs 77%, P < .001). CONCLUSION: Tonsillectomy was one of the most common ambulatory surgical procedures in 2010 in the United States. The majority of patients were low risk, but some at higher risk were included (age ≤3 years and obstructive sleep apnea). The National Hospital Ambulatory Medical Care Survey estimates provide useful baseline data for future research on quality measures and outcomes.