Introduction

Adenoid and tonsil hyperplasia is of the most common disorders in ENT offices. It is the most common cause of sleep apnea syndrome in pediatric patients accounting for 70 to 75% of the cases1, and pharyngeal and palate excision (adenotonsillectomy) is the treatment of choice. 2 It is the major surgical procedure performed among ENT doctors. 3

To this date, there are still some controversies about surgery indication. After the initial excitement with the performance of this surgery in the first half of the century, the number of indications decreased with the increase of the knowledge about the valuable immune role of tonsils. Currently accepted indications are as follows: adenoid and tonsil hypertrophy (sleep apnea syndrome and cor pulmonale), recurrent tonsillitis, rheumatic fever and glomerulonephritis, halitosis, recurrent rhinosinusitis, otitis media with secretion.3

Obstructive apnea is associated with poor school performance, cor pulmonale4, atypical behavior disorders, hyperactivity, delayed development, day sleepiness and distraction.5 Most of these children are mouth breathers, and therefore present complaints of poor appetite and swallowing difficulties.5,6,7

Delayed growth is the most severe effect of obstructive sleep apnea syndrome 8. Growth retardation resulting from adenoid and tonsil hypertrophy was described in the literature; however, most of the studies were case reports 9, 10. Few of those reports had more than 20 individuals, and few quotations from Brazil. Pre operative and long-term postoperative follow up is required for those children that have undergone surgery, in order to detail information about growth rate after the procedure.8

The objective of this study is to measure growth and development of children before and after adenotonsillectomy comparing height and weight percentile for three months before and after adenotonsillectomy.

Material and Methods

Fifth-five pediatric patients were studied (32 girls and 33 boys) randomized from those patients waiting in line to undergo adenotonsillectomy referred to our service care. Children were included according to the following criteria:

 Age between 3 and 13 years;
 Clinical symptoms of sleep apnea syndrome (snoring, apnea, mouth breather, swallowing disorders) - According to the questionnaire (Chart 1);
 Palatine tonsils and pharyngeal hypertrophy (stage III and IV) causing upper airways obstruction. Classification level of sleep apnea used was according to Brodsky description 11 for palatine tonsil and level of obstruction of nasopharynx airway column evaluated through simple X-ray of the paranasal sinuses.

Children with other systemic diseases, craniofacial anomalies and neurological disorders were excluded.
All children underwent antropometrical classification of weight and height preoperatively and 6 months after surgical procedure.

The values of weight (Kg) and height (cm) were compared against child growth curve of Brazilian Population12, specific for each gender, before and after surgery, and were classified according to weight and height percentiles.

Parents and guardians of the children signed an informed consent about this research, and the Board of Ethics and Research of The Clinical Hospital of Medical School of the University of Sao Paulo approved such consent form.

For the statistical analysis McNemar non-parametric test was used with a significance level of 5% to compare pre and postoperative percentiles.


Chart 1. Questionnaire *

1. How much does your child sleep:
- Does the child snore half of the time?
- Does the child always snore?
- Is the snore loud?
- Is breathing noisy?

2. Your child:
- Breaths with the mouth opened during the day?
- Has dry mouth when wakes up?
- Has nocturia?
- Wakes up tired in the morning?
- Is sleepy during the day?
- Is difficult to wake up in the morning?
- Has headache when wake up?

3. Have you ever observed if your child stop breathing during the night?

* adapted from the Pediatric sleep questionnaire of sleep disorder breathing (Chervin et al., 2000)



Results

Fifty-five children were studied (32 girls and 33 boys) aged from 3 to 13 years (mean 5.9± 2.9 years).
Table 1 and 2 show antropometrical data of children pre and postoperatively. We observed that most of the children (78.2%) had a height percentile below 75 and as for the weight; most of the children (70.9%) had a percentile below 50. The comparison of height in the pre and postoperative reported a significant change in distribution of children both for weight and height, with increased number of children placed at higher percentiles in the postoperative, demonstrating that there was higher development within this time period.





Discussion

It is common knowledge that adenoid and tonsil hyperplasia is one of the major causes of obstructive sleep apnea syndrome in children and delayed growth might be present in such patients. 13

Prevalence of delayed growth in children with adenoid and tonsil hypertrophy ranges from 1 to 46%. In the group studied, most of the patients were within the percentile below 75% for height and below 50% for weight, whereas in normal population there is a certain balance in the distribution of individuals within this age range due to other factors, mainly genetic ones.12.

After 6 months postoperatively, there was a change in the distribution of children according to percentile of height and weight, which was found more balanced among the groups. Thus, there was a statistically significant difference, showing higher growth rate of children 6 months after adenotonsillectomy. Growth speed was also significant and justified the change in percentile, which confirmed the findings of other authors.2

This piece of data was also in accordance with Williams' study, 199113, that reported an increase in children's weight and height six months after tonsillectomy therapy.

There are several explanations for the improvement of development in children after excision of palatine and pharyngeal tonsils. Mouth breathing due to adenoid and tonsil hyperplasia result in swallowing, olfactory and mastication disorders 5, 6,7that may be associated with poor appetite5 and low calorie intake.

We could observe in other series of studies that mastication and swallowing were significantly improved7, which could make food intake easier, however other authors found out that calorie intake before and after adenotonsillectomy was similar15. The literature also mentioned the correlation with low oxygen saturation in blood, sleeping acidosis and increase in energy consumption caused by increased respiratory efforts 16. Recent studies reported that 34 to 61% of children with adenoid and tonsil hypertrophy that have undergone surgery presented several degrees of hypoxemia and sleeping disorders, which were abnormal.8

Sleeping disorders in severe adenoid and tonsil hyperplasia are very common and associated with apnea. Commonly these patients have nightmares, nocturnal enuresis, and frequent wakefulness5.

Since sleep apnea may cause frequent wakefulness it is associated with irregular GH (Growth Hormone) release affecting growth.8 An increase in GH secretion was observed after adenoidtonsillectomy8,16 , as well as increased secretion of IGF-I (Insulin-like Growth Factor) and IGFBP3 (insulin-like Growth Factor linked to Protein B3), which is responsible for the anabolic effect of GH16.

Growth hormone release occurs during sleeping time, mainly during pre-puberty years. Hormone secretion increases rapidly in short waves during sleeping time in children at this age range17,18. It is believed that a breakdown in sleeping pattern of children results in frequent wakefulness and, therefore, apnea mainly during the short wave sleeping phase. This would be the mechanism responsible for reducing GH secretion19. The treatment of sleep apnea would reverse this picture, facilitating normal growth of children after adenotonsillectomy.

Clinical history is critical and has positive outcome value of approximately 90 to 100% if compared with polysomnography 20. In association with pharynx examination and growth curve analysis, it could direct the surgical treatment of adenoid and tonsil hyperplasia. 1.

Normal growth is a sign of good health, sick children have decreased growth rate. For this reason, growth should be monitored in all children and normally it is carried out by primary care pediatrician 21. This Professional should carefully pay attention to reports from the mother or guardian of the patient as for sleep apnea, and if such person does not mention it, he/she should notice the symptom of mouth breathing and occasional craniofacial effects resulting from it such as elongated face, retrognathia, maxillary atresia, dark circles under the eyes, etc 6. Since they are very common respiratory symptoms during sleep, they are of little importance for parents, mainly snoring, symptom common at all different ages and many times it is not considered a disease. Therefore, parents do not mention it during normal routine appointment. For this reason, final diagnosis of sleep apnea due to adenoid and tonsil hyperplasia may take two years. 1

We concluded that adenoid and tonsil hyperplasia with consequent sleep apnea affects weight and height development in children and adenotonsillectomy contributed to their recovery. Therefore, its diagnosis and treatment should be made at an early stage in order to prevent its irreversible effect in pediatric patient's growth and development.

References

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1 Assistant Physician, Division of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of São Paulo.
2 Speech and hearing therapists, Division of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of São Paulo.
3 Graduate, Focus on Otorhinolaryngology, Medical School, University of São Paulo.
4 Former resident physician, Division of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of São Paulo.
Address correspondence to: Rua Guarará 529 cj. 121 São Paulo SP 01425-001
Tel (55 11)3889-0359 - Fax (55 11)3887-6387 - E-mail: difran@attglobal.net
Study awarded with Special Citation, 36o Congresso Brasileiro de Otorrinolaringologia, Florianopolis, 19 - 23 de November, 2002.
Article submitted on January 30, 2003. Article accepted on February 13, 2003.