Comparative Evaluation of the Effects of Adenotonsillar Hypertrophy on Oral Health in Children.

We aimed to investigate the oral health of children in terms of the presence of dental caries, periodontal health, halitosis, and dentofacial changes in patients who had adenotonsillar hypertrophy related to mouth breathing and compared these findings with nasal breathing healthy and adenotonsillectomy-operated children. The patient group comprised 40 mouth-breathing children who were diagnosed with adenotonsillar hypertrophy, while the control group consisted of 40 nasal breathing children who had no adenotonsillar hypertrophy. Forty children who had undergone an adenotonsillectomy operation at least 1 year prior to the study were included in the treatment group. Oral examinations of all children were conducted, and the parents were asked about medical and dental anamnesis, demographic parameters, toothbrushing and nutrition habits, oral health-related quality of life (OHRQoL), and symptoms of their children. Demographic parameters, toothbrushing and nutrition habits, and the presence of bad oral habits did not differ between groups (p > 0.05). Adenotonsillectomy is associated with a remarkable improvement in symptoms; however, some symptoms persist in a small number of children. The salivary flow rate, dmft/s, DMFT/S index, plaque, and gingival index scores did not differ between groups (p > 0.05). The patient group showed higher rates of halitosis when compared with the treatment and control groups (p < 0.001). Mouth breathing due to adenotonsillar hypertrophy caused various dentofacial changes and an increase in Class II division 1 malocclusion (p < 0.001). It was shown that adenotonsillar hypertrophy does not negatively affect OHRQoL, it could be a risk factor for dental caries, periodontal diseases, and halitosis, but by ensuring adequate oral health care, it is possible to maintain oral health in children with adenotonsillar hypertrophy. Also, it is recommended that orthodontic treatment should start as soon as possible if it is required. In this context, otorhinolaryngologists, pedodontists, and orthodontists should work as a team in the treatment of children with adenotonsillar hypertrophy.

Bilateral synchronous tonsillar metastasis from a mixed form of neuroendocrine tumor in the lung: Case report and literature review.

Here, we report the case of a 54-year-old man with a history of squamous cell carcinoma (SCC) of the lung, who developed bilateral neuroendocrine carcinoma (NEC) of the palatine tonsils. Faced with this atypical situation, another biopsy of the lung lesion was performed, revealing NEC histology patterns. This article describes the first case of metastasis to the bilateral palatine tonsils from the NEC component of a mixed NEC/SCC of the lung, highlighting the importance of reconsidering the diagnosis of the primary tumor histology, particularly in lung cancer with the possible presence of mixed tumor after phenotype transdifferentiation of the primary tumor. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Mixed lung carcinoma can be revealed after the presence of neuroendocrine carcinoma metastasis. WHAT THIS STUDY ADDS: Bilateral neuroendocrine carcinoma of the palatine tonsils should be considered as metastases, particularly in the presence of lung cancer with a poor response to treatment.

Sleep endoscopy findings in children in supine versus left lateral position.

OBJECTIVE: To describe how drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea (OSA) change with lateral positioning. METHODS: Children undergoing DISE for OSA in 2018-19 at a tertiary care children's hospital were positioned first supine and then in left lateral (LL) and findings were compared. RESULTS: 63 children were included, 30 (47.6%) female and 33 (52.4%) male, mean age 4.64 years, and a mean Z-score 0.70. Mean pre-op Apnea Hypopnea Index (AHI) was 6.41 and REM AHI was 15.04. In supine position, 20 had obstruction at the palate (31.7%), 39 (61.9%) had obstruction at each of the base of tongue and the larynx, 17 (27.0%) had obstruction at the tonsils. In LL position, 11 (17.5%) were obstructed at the palate, 21 (33.3%) at the tonsils, 8 (12.7%) at the base of tongue and 7 (11.1%) at the larynx. Larynx and base of tongue were most likely to improve in LL position, as 54% of patients obstructed in supine position were open in LL position. Overall 38 (60.3%) patients improved on LL, 18 (28.6%) had no change, and 7 (11.1%) worsened. 30 (47.6%) patients improved in 1 site while 12 (19.0%) improved in more than 1 site. 16 (25.4%) patients worsened in 1 site and 9 (56.3%) of these had improvement in another site. CONCLUSION: A significant number of patients improved airway patency, particularly at the base of tongue/larynx, during DISE when placed in LL position as compared to standard supine positioning.

The prevalence of human papillomavirus in pediatric tonsils: a systematic review of the literature.

BACKGROUND: HPV-related head and neck cancer rates have been increasing in recent years, with the tonsils being the most commonly affected site. However, the current rate of HPV infection in the pediatric population remains poorly defined. The objective of this study was to systematically review and evaluate the prevalence and distribution of HPV in the tonsils of pediatric patients undergoing routine tonsillectomy. METHODS AND RESULTS: The literature was searched using PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and ProQuest Dissertations & Theses Global databases (inception to December 2017) by two independent review authors. Inclusion criteria included articles which evaluated the prevalence of HPV in a pediatric cohort without known warts or recurrent respiratory papillomatosis, those which used tonsil biopsy specimens for analysis, and those with six or more subjects and clear outcomes reported. Eleven studies met the inclusion criteria. Using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, two reviewers appraised the level of evidence of each study, extracted data, and resolved discrepancies by consensus. The systematic review identified 11 articles (n = 2520). Seven studies detected HPV in the subject population, with prevalence values ranging from 0 to 21%. The level of evidence for all included studies was OCEBM Level 3. CONCLUSIONS: HPV may be present in pediatric tonsillectomy specimens; however, the largest included study demonstrated a prevalence of 0%. Future testing should be performed using methods with high sensitivities and specificities, such as reverse transcript real-time PCR or digital droplet PCR.

Formula for the prediction of apnea / hypopnea index in children with obstructive sleep apnea without polysomnography according to the clinical parameters: Is it reliable?

PURPOSE OF THE STUDY: The aim of the study was to propose "the risk formula" for obstructive sleep apnea in children according to the general and local clinical parameters and findings relevant for obstructive sleep apnea (OSA) severity. The unmet need for this formula arises from the economic burden of polysomnography (device, staff, training, special sleep centers, etc) as the golden standard for the diagnostics. MATERIALS AND METHODS USED: The study was performed from January 2013 until January 2016 in the Sleep Center, Department for Neuroscience, School of Medicine of the University of Split, Department of Pediatrics, University Hospital Split, Croatia and ENT Dept. University Hospital in Split, Croatia. Inclusion criteria were: age > two years, AHI >1 diagnosed by polysomnography. Exclusion criteria were: chronic lung disease, active tonsillitis/pharyngitis at the time of the physical exam and syndromes that affect breathing. All polysomnograms were scored by a qualified sleep technologist and interpreted by two board certified sleep physicians independently. Age, sex, BMI, Mallampati score, tonsillar size and adenoids size were recorded. All statistical calculations were performed using SPSS 20. RESULTS: In total 60 children were included in the study. The median of age was 5 years (range 2-9). There were 19 (32%) girls and 41 (68%) boys. Of all evaluated predictors, there were statistically significant differences in the values of AHI among children with different modified Mallampati score (χ2 = 28.2; p < 0.001), different size of tonsils (χ2 = 25.3; p < 0.001) and different size of adenoids (z = 2.7; p = 0,006) in univariate regression analysis. Strong positive association of AHI with modified Mallampati score (standardized B = 0.51; partial correlation = 0.542, r = 0.631) was found, as well as positive correlation of AHI with tonsillar size (standardized B = 0.246; partial correlation = 0.295,R = 0.489) in the multivariate forward stepwise regression analysis. CONCLUSION: Even though we are aware that PSG is the gold standard for diagnostics of SDB there is a significant financial burden for this diagnostic procedure. That is why there is a necessity for establishing good clinical standards and possible formula for OSA severity evaluation. We propose formula which includes Mallampati score and tonsillar size for OSA -risk calculation in order to perform early therapeutic intervention thereby reducing the risk of long-term negative consequences. We recommend this formula as the screening formula in circumstances where PSG is not available, in cases when the "waiting list" is too long or when a child can not cooperate to perform it. In developing countries like Croatia on time intervention with reduced procedure-associated costs is of the utmost importance.

Montelukast for Children with Obstructive Sleep Apnea: Results of a Double-Blind, Randomized, Placebo-Controlled Trial.

RATIONALE: Obstructive sleep apnea (OSA) is highly prevalent in children and is usually treated by adenotonsillectomy. Nonsurgical therapies for OSA consist primarily of antiinflammatory approaches and have gained popularity, but their efficacy remains to be critically examined. OBJECTIVES: To determine the effect of montelukast on pediatric OSA. METHODS: A prospective randomized double-blind controlled trial of polysomnographically diagnosed OSA in children ages 2-10 years who were treated with either oral montelukast (4 or 5 mg daily) or placebo for 16 weeks. Adherence to the medication was ascertained using automated timed pill dispensers along with weekly telephonic reminders. MEASUREMENTS AND MAIN RESULTS: Ninety-two children diagnosed with OSA were approached, and 64 (69.6%) agreed to participate. Of these, 57 (89.0%) completed the 16-week trial, 28 in the montelukast group and 29 in the placebo group. Age, sex, and percentage of obesity were similar in the two groups, as were initial apnea-hypopnea index (AHI) scores. Overall, intention-to-treat analyses revealed that beneficial effects occurred in 20 children receiving montelukast (71.4%), whereas only 2 (6.9%) of the children receiving placebo showed reductions in AHI score (P < 0.001). Indeed, AHI decreased from 9.2 ± 4.1/hour total sleep time (TST) to 4.2 ± 2.8/hour TST (P < 0.0001) in montelukast-treated children, whereas in children receiving placebo, the AHI did not change (from 8.2 ± 5.0/h TST before to 8.7 ± 4.9/h TST at completion of the trial). CONCLUSIONS: When compared with placebo, montelukast for 16 weeks effectively reduced the severity of obstructive sleep apnea in children 2-10 years of age. These results support a therapeutic role for leukotriene modifiers in pediatric OSA provided that long-term trials confirm current findings. Clinical trial registered with www.clinicaltrials.gov (NCT 00599534).

The relevance of tissue thiol histochemistry to diagnostic hematopathology.

Expression analyses suggest that alterations of the antioxidant state of some diffuse large B-cell lymphomas can assist prognosis; reversibly oxidized thiols may serve as a surrogate marker for identifying such cases. Little is known about the distribution of free thiols and reversibly oxidized thiols in human tissues. We developed a staining technique that enables visualization of tissue thiols in situ using bright field microscopy and validated it using gastrointestinal tissue specimens. We used our thiol staining technique to assess benign tonsillectomy and diffuse large B-cell lymphoma specimens. The gastrointestinal series revealed the presence of free thiols within epithelial cells and cells of the lamina propria. Staining for reversibly oxidized thiols was robust in gastric foveolar cells, intestinal goblet cells and the mucus they produce. Tonsillectomy specimens exhibited diffuse presence of free thiols. Staining for reversibly oxidized thiols was confined to germinal center macrophages and sinus histiocytes. Among the diffuse large B-cell lymphoma specimens, we observed strong staining for free thiols within malignant cells. By contrast to benign B-cells, the malignant cells demonstrated pronounced and diffuse staining for reversibly oxidized thiols. We demonstrated intrinsic differences between benign and malignant cells.

Feasibility of rapid discharge after transoral robotic surgery of the oropharynx.

OBJECTIVES/HYPOTHESIS: To investigate the use of an algorithm for rapid discharge after transoral robotic surgery (TORS) and its effect on postoperative complications. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of TORS cases from September 2009 to February 2013 was conducted. The effect of patient and tumor characteristics on postoperative length of stay (LOS) and complications were analyzed. RESULTS: A total of 91 patients were included; 79 underwent TORS for malignancy and 12 for a benign process. The mean LOS was 1.51 days (range, 1-5 days) with a median of 1 day. The mean time to initiation of oral diet was 1.26 days (range, 1-7 days) with a median of 1 day. Eleven (12%) patients experienced one or more complications during their postoperative course. Multivariate analysis demonstrated a significant association between patient and procedure variables and postoperative complications. TORS base of tongue reduction for obstructive sleep apnea (OSA) was associated with a significantly greater mean incremental time to initiation of oral diet (1.0 days, 95% confidence interval [CI]: 0.4 to 1.7, P < .001). A significantly greater mean incremental LOS was observed for patients with advanced comorbidity and a delay in initiation of oral diet beyond 24 hours. CONCLUSIONS: Rapid initiation of oral diet and rapid discharge home is feasible and not associated with postoperative complications. Similarly, the performance of a concurrent neck dissection does not contribute to LOS or the development of postoperative complications. Patients undergoing TORS for OSA are at greater risk of delay in initiation of oral diet and increased LOS. LEVEL OF EVIDENCE: 4

Serum lipids alterations in adenoid hypertrophy or adenotonsillar hypertrophy children with sleep disordered breathing.

OBJECTIVES: We aimed to investigate metabolic parameters in children with adenoid hypertrophy (AH) only or adenotonsillar hypertrophy (ATH) and compare them with healthy controls. METHODS: Forty-four prepubertal children aged 6-12 years who were obstructive symptoms and 16 healthy children were recruited in this study. All children underwent a complete otolaryngologic examination and sleep screening. The patients were divided into three groups according to obstruction type: normal, AH (adenoid grade III or IV, tonsil grade 1 or 2), and ATH (adenoid grade III or IV, tonsil grade 3 or 4). All participants underwent hematologic and biochemical tests including fasting blood glucose, insulin, and plasma lipids. RESULTS: (1) The children with AH and ATH had lower high-density lipoprotein cholesterol (HDL-C), when compared to normal children. (2) The level of HDL-C was negatively correlated with the sum of adenoid and tonsillar size scores and the apnea-hypopnea index (AHI) (r=-0.477, p<0.001 vs. r=-0.548, p<0.001, respectively). There was a modest association between HDL-C and minimal SpO2 (r=0.332, p=0.009). (3) Stepwise multiple regression analysis identified the AHI, triglycerides, and fasting insulin as independent predictors for HDL-C. CONCLUSIONS: Patients with adenoid and tonsil hypertrophy had low HDL-C. HDL-C levels are inversely related to the sum of adenoid and tonsillar size scores and AHI in SDB children. HDL-C may be a sensitive indicator of serum lipids changes in SDB children.

Interactions of obstructive sleep-disordered breathing with recurrent wheezing or asthma and their effects on sleep quality.

Snoring is the most characteristic symptom of obstructive sleep-disordered breathing (SDB) and recurrent wheezing is the most common clinical manifestation of asthma. The purpose of the present review is to outline the impact of SDB and recurrent wheezing/asthma on sleep quality and to summarize the epidemiologic and pathophysiologic evidence supporting an association between the two disorders. Enlarged tonsils and adenoid or obesity predispose to obstructive sleep apneas and hypopneas which are accompanied by arousals, restless sleep, and frequently daytime sleepiness, inattention, hyperactivity, and academic difficulties. Subjects with history of wheezing are also at risk for sleep disturbance and daytime cognitive dysfunction. Asthmatic children have more frequent snoring, apneas, and hypopneas during sleep than non-asthmatic subjects and tonsillar hypertrophy mediates at least in part this epidemiologic association. In addition, preliminary evidence indicates that treatment of sleep apnea with adenotonsillectomy results in improved control of coexisting asthma. Elevated concentrations of leukotrienes and oxidative stress markers have been detected in the exhaled breath condensate of children with asthma and probably contribute to bronchoconstriction. Moreover, sleep apneic children have increased expression of leukotrienes and leukotriene receptors in adenotonsillar tissue. Viral respiratory infections may induce inflammation and oxidative stress in the asthmatic airway enhancing not only bronchospasm, but also biosynthesis of leukotrienes within pharyngeal lymphoid tissues, which promote adenotonsillar enlargement and sleep apnea. In conclusion, taking under consideration the epidemiologic association between obstructive SDB and asthma, when one of the two disorders is diagnosed, the possibility of the other disease being present should be entertained. Pediatr. Pulmonol. 2011; 46:1047-1054. © 2011 Wiley Periodicals, Inc.

Outcome, risk, and error and the child with obstructive sleep apnea.

Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea syndrome (OSAS). However, there is evidence that the child with severe OSAS is at increased risk of respiratory compromise. The most difficult risk factor to assess is the severity of OSAS, and these difficulties are reviewed.

Morphological features of elderly patients with obstructive sleep apnoea syndrome: a prospective controlled, comparative cohort study.

OBJECTIVES: To investigate the pharyngeal morphologic features and its pathogenic role on obstructive sleep apnoea syndrome in the elderly population. DESIGN: Prospective controlled, comparative cohort study. SETTING: Territory referral centre. PARTICIPANTS: We enroled 320 consecutive patients with complaints of snoring who visited Nagoya University Hospital from January 2004 to December 2007. We also collected 26 control subjects aged over 60 years from community-dwelling people. MAIN OUTCOME MEASURES: We underwent a morphological evaluation, measurement of nasal resistance, assessment of daytime sleepiness and nocturnal polysomnography. RESULTS AND CONCLUSIONS: Two hundred and ninety-two patients were analysed. The constitution ratio of men, the body mass index and Epworth sleepiness scale were decreased with ageing. Tonsil size was reduced progressively with ageing. Retroglossal space was wider, and soft palate was lower in ≥ 60 year group than in < 40 year group. Retroglossal space was wide in elderly patients with sleep apnoea compared with control subjects. Tonsil size was not correlated to apnoea/hypopnoea index in ≥ 60 year group unlike the other generations. Modified Mallampati Score and tongue size were significantly but mildly correlated only in ≥ 60 year group. Width of fauces was correlated in all the groups. Multiple regression analysis showed that body mass index, age, gender, tonsil size and width of fauces were independent factors for apnoea/hypopnoea index. CONCLUSIONS: Morphologically, the tonsil could play a minor role but the width of fauces could play relatively a major role. Additionally, wide retroglossal space, low positional soft palate and large tongue size may be characteristics for elderly patients of obstructive sleep apnoea syndrome.

[Improved diagnosis of the severity of chronic decompensated tonsillitis].

Results of examination and treatment of 111 patients were used to evaluate the severity of chronic decompensated tonsillitis based on the following parameters of endotoxicosis: leukocytic intoxication index, content of medium molecular-weight peptides in blood, and erythrocyte sorption capacity. These results provided additional information about the functional state of palatine tonsils and severity of tonsillogenic intoxication; moreover they made it possible to evaluate efficiency of conservative treatment and determine indications for surgical intervention. Taken together, these data may be used to avoid subjective conclusions as regards the degree of decompensation in patients with chronic tonsillitis.

[Absence of positional effect in children with moderate-severe obstructive sleep apnea syndrome].

BACKGROUND: Sleep apnea syndrome (SAS] is common in both adults and children (amongst whom it is estimated at 2-3%). This syndrome significantly affects the child's daily activities and development. Research in adults has demonstrated a direct relationship between sleeping supine and the severity of sleep apnea syndrome. Very few studies were conducted among children and the findings were controversial. AIM: The goal of this study was to continue examining and establishing the relationship between children's sleep position and the severity of sleep apnea syndrome. METHODS: The study group consisted of 25 children with cLinically suspected obstructive sleep apnea [OSA), referred to the Technion's Sleep Lab for confirmation of this diagnosis. The study course included nocturnal recording of the children and closely monitoring their sleep position. Data analysis included a comparison of the various data regarding the severity of the children's respiratory disturbance, at each stage of sleep and in each sleeping position separately. Analysis of the results was performed using the paired T test. RESULTS: Sixteen boys and 9 girls aged 5.5 years (range 2-12 years) with various severity of OSA, most of them with moderate-severe degree of sleep apnea, [average respiratory disturbance index of 14.7 +/- 12.3/h) were studied. In most children the recording consisted of all sleep postures, but no statistically significant relationship was found between the various sleeping positions and the severity of OSA, neither in REM sleep nor in NREM sleep. CONCLUSIONS: We believe that the absence of positional effect in children with moderate-severe obstructive sleep apnea syndrome results from a different mechanism and site of obstruction. While in adults the Location of obstruction is mostly retroglossal or retropalatal, in children it is usually at the levels of tonsils and adenoids.

Characterization of CSF hydrodynamics in the presence and absence of tonsillar ectopia by means of computational flow analysis.

BACKGROUND AND PURPOSE: Phase-contrast MR imaging (PCMR) has only partially characterized cyclic CSF flow and pressure, which, hypothetically, have a role in the pathogenesis of syrinx and symptoms in the Chiari I malformation. Our goal was to use computational flow analysis (CFA) to better understand CSF hydrodynamics. MATERIALS AND METHODS: High-resolution MR images were obtained in a healthy volunteer and a patient with Chiari I malformation. With standard segmentation and discretization techniques, 3D models of the subarachnoid space, cerebellum, and spinal canal were created. CSF flow during systole and diastole were simulated with the boundary element method in the models. CSF velocities and pressures computed in the patient with Chiari I malformation were compared with those in the healthy volunteer. Flow patterns were also compared with PCMR results for validation of the technique. RESULTS: The CFA and PCMR results agreed well. Inhomogeneous flow patterns characterized by fluid jets anterior and lateral to the spinal cord were demonstrated in both the Chiari I and volunteer models by CFA. Significant circumferential velocities were evident, suggesting swirling flow in the spinal canal. Higher magnitude jets were found in the patient with Chiari I than in the healthy volunteer. Relatively even pressure gradients were found along the spinal canal in both cases, with a 50% steeper gradient in the patient with Chiari I malformation. CONCLUSIONS: Circumferential velocities and pressure gradients in the spinal canal, which may be clinically relevant to Chiari I and other malformations, can be obtained by CFA in patient-specific geometries.

The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents.

The prevalence of childhood obesity is increasing worldwide. One of the obesity-related complications that has received increasing attention in recent years is sleep-disordered breathing. Obese children are at a higher risk of developing sleep-disordered breathing, including habitual snoring, obstructive sleep apnea syndrome and desaturations preceded by central apneas. Both adiposity and upper airway factors, such as adenotonsillar hypertrophy, modulate the severity of sleep-disordered breathing in these children. Adenotonsillectomy seems to be effective against obstructive sleep apnea syndrome in obese children. On the other hand, there are limited data on the effects of weight loss and of treatment with continuous positive airway pressure on the severity of sleep apnea in obese children and adolescents.

Microdebrider vs electrocautery: a comparison of tonsillar wound healing histopathology in a canine model.

OBJECTIVE: To evaluate tonsillar wound healing histopathology in a canine model following microdebrider intracapsular and electrocautery tonsillectomy techniques. STUDY DESIGN: Randomized, controlled, single-blinded, paired comparison of histopathology. SUBJECTS AND METHODS: Twelve beagles underwent tonsillectomies by microdebrider on one side and electrocautery on the other. Punch biopsies were taken of the tonsillar fossae on postoperative days 3, 9, and 20. Specimens were graded with a novel mucosal wound healing scale (inter-rater reliability, r = 0.83) and appropriate statistical analysis performed. RESULTS: Combined mucosal wound healing scale scores showed significantly faster healing on the microdebrider side when compared to the electrocautery side on postoperative day 3 and day 9 (P < 0.05), which equalized by day 20. CONCLUSION: In a canine model of tonsillar wound healing, microdebrider intracapsular tonsillectomy produced significantly faster healing than electrocautery tonsillectomy in the early postoperative course. The "biologic dressing" theory of intracapsular tonsillectomy wound healing may account for observed differences in healing and suggests a mechanism for improved clinical outcomes.