OBJECTIVE: Pediatric obstructive sleep apnea (OSA) caused by adenoids or an enlarged palatine tonsil has a negative impact on physical and mental growth. Surgical removal of the tissue is effective but entails a life-threatening risk of postoperative bleeding, which is up to 30 times higher in chronic pediatric disease cases. However, endoscopes and resection devices provide safe, reliable surgical methods. Here, we report the efficacy and safety of endoscopic powered intracapsular tonsillectomy and adenoidectomy (PITA) for pediatric OSA in patients with high-risk comorbidities.
METHODS: This retrospective case series included pediatric patients with OSA who underwent PITA at a single tertiary medical center between April 2017 and May 2023. Ten patients (three males and seven females; mean age 6.4 years, range 2-12 years) were included; all met the Japanese criteria for complex chronic pediatric conditions.
RESULTS: The average operative time was 61 min; a microdebrider was used in eight cases and a coblator in two cases. Although there was no postoperative bleeding, one case experienced regrowth.
CONCLUSIONS: Our data show that an endoscopic PITA approach could reduce the risk of severe bleeding and relieve the sleeping conditions of pediatric patients with complex chronic OSA.

BACKGROUND: Crouzon syndrome is an extremely rare craniofacial dysplasia, which is mainly caused by the early ossification and closure of the coronal suture of the skull. Craniofacial deformities can cause stenosis of the nasal cavity and posterior nasal meatus, resulting in sleep apnea.
METHODS: A 9-year-old boy with sleep snoring for 6 years, progressive aggravation in the past 1 month and accompanied by apnea during sleep.
METHODS: This case was diagnosed with Crouzon syndrome complicated with severe obstructive sleep apnea and severe hypoxemia.
METHODS: After adenoidectomy, he was admitted to the pediatric intensive care unit with ventilator-assisted respiration. During this period, the blood oxygen saturation fluctuated greatly. After trying to extubate, the blood oxygen was difficult to maintain and had to be intubated again. After active treatment, extubation was successful.
RESULTS: The wound of nasopharynx recovered well and the sleep state was significantly improved 3 months postoperation.
CONCLUSIONS: It is suggested that the time of ventilator-assisted breathing should be prolonged and the perioperative airway management should be strengthened in order to reduce the risk of postoperative complications.

OBJECTIVE: Exploring a possible link between upper airway inflammation and the development of cholesteatoma by studying the association between mucosa-affecting diseases of the upper airways and cholesteatoma surgery.
METHODS: This is a nationwide case-control study of 10,618 patients who underwent surgery for cholesteatoma in Sweden between 1987 and 2018. The cases were identified in the National Patient Register and 21,235 controls matched by age, sex and place of residency were included from national population registers. Odds ratios (OR) and corresponding 95% confidence intervals were used to assess the association between six types of mucosa-affecting diseases of the upper airways and cholesteatoma surgery.
RESULTS: Chronic rhinitis, chronic sinusitis and nasal polyposis were more common in cholesteatoma patients than in controls (OR 1.5 to 2.5) as were both adenoid and tonsil surgery (OR > 4) where the strongest association was seen for adenoid surgery. No association was seen between allergic rhinitis and cholesteatoma.
CONCLUSIONS: This study supports an association between mucosa-affecting diseases of the upper airways and cholesteatoma. Future studies should aim to investigate the mechanisms connecting mucosa-affecting diseases of the upper airways and cholesteatoma formation regarding genetic, anatomical, inflammatory and mucosa properties.

BACKGROUND The adenoids are lymphatic tissue located in the nasopharynx and play a role in upper-airway immunity. Inflammation of the adenoids is called adenoiditis, which can cause a variety of symptoms. This is a common condition and is due to acute viral or bacterial infection. Most patients experience mild symptoms of upper-respiratory tract infection with a self-limiting course. CASE REPORT A 5-year-old female patient was brought into the clinic by her parents with concerns regarding hearing and sleep. Clinical assessment was consistent with persistent otitis media with effusion and sleep-disordered breathing. She was scheduled for surgery, including nasendoscopy, adenoidectomy, and bilateral grommet insertion. During surgery, direct visualization of the postnasal space showed complete obstruction by hypertrophic, inflamed adenoids covered in a thick, white film. A biopsy was taken, which detected herpes virus cytopathic effect. A diagnostic workup excluded a neoplastic process and other bacterial or fungal infections. A trial of oral antiviral medication was successful and follow-up nasendoscopy showed resolution of adenoid hypertrophy. CONCLUSIONS Direct visualization of the postnasal space, with a transoral mirror or 120-degree endoscope, prior to adenoidectomy can aid diagnosis. Adenoiditis may be caused by a wide range of organisms, including herpes virus. Active mucopurulent discharge should raise concern for infection by bacteria, fungi, or virus. Previous research on viral infection of the adenoids have been in asymptomatic patients with presumed latent infection and undergoing elective adenoidectomy. To our knowledge, this is the first paper to report on successful treatment with antiviral medication alone.

Congenital myasthenic syndromes are rare genetic diseases involving pathologic proteins in the neuromuscular junction. Malignant hyperthermia susceptibility is a genetic disorder involving a hypermetabolic response to volatile anesthetics and depolarizing neuromuscular blocking agents. We present the first reported case of a 3-year-old boy with both congenital myasthenic syndrome and malignant hyperthermia susceptibility, resulting from a mutation in the ryanodine receptor type 1 gene, who underwent an adenotonsillectomy for severe obstructive sleep apnea. We discuss the anesthetic challenges in navigating these 3 comorbidities in the setting of airway surgery.

This study aims to investigate the effects of obstructive sleep apnea on paediatric psychological and behavioural abnormalities. A total of 1086 paediatric patients with obstructive sleep apnea and 728 sample snoring controls were enrolled in the study. Patients with obstructive sleep apnea underwent bilateral tonsillectomy plus adenoidectomy or adenoidectomy alone. Repeated Autism Behaviour Checklist, Spence Children\'s Anxiety Scale, and Children\'s Depression Inventory were performed to assess the autism symptoms, anxiety level and depressive symptoms before and after surgery. The score of Autism Behaviour Checklist in preschool children with obstructive sleep apnea was higher than that in control. In school children with obstructive sleep apnea, the score of Spence Children\'s Anxiety Scale was also higher. School children with obstructive sleep apnea with depressive symptoms were significantly higher than that in control. The scores of Autism Behaviour Checklist, Spence Children\'s Anxiety Scale, and Children\'s Depression Inventory in the obstructive sleep apnea group after surgery were significantly lower than that before surgery. Our study showed that the score of Spence Children\'s Anxiety Scale and Children\'s Depression Inventory had a close correlation with the illness course and hypoxia duration. The Spence Children\'s Anxiety Scale and Children\'s Depression Inventory scores are also closely associated with the Autism Behaviour Checklist score. These results suggest that obstructive sleep apnea may have a significant impact on autism symptoms, anxiety levels and depressive symptoms in children. We found that the longer the duration of the obstructive sleep apnea course and hypoxia, the greater the impact on anxiety level and depressive symptoms. The suspected autism symptoms, anxiety level and depressive symptoms in children with obstructive sleep apnea were also significantly correlated. Thus, early detection and timely treatment may often reverse the psychological and behavioural abnormalities caused by obstructive sleep apnea.

OBJECTIVE: Safe surgery for pediatric patients with obstructive sleep apnea (OSA) is important to decrease postoperative events and improve cost-effectiveness. Therefore, this study aimed to compare surgical efficacy and safety between powered intracapsular tonsillectomy and adenoidectomy (PITA) and extracapsular tonsillectomy and adenoidectomy for OSA in children.
METHODS: In this retrospective case-control study, patient characteristics and postoperative outcomes were compared between 93 children with OSA who underwent PITA and 81 children who underwent conventional extracapsular tonsillectomy and adenoidectomy at a tertiary hospital. Data analysis using multivariate, multiple regression, and binomial logistic regression analyses was performed.
RESULTS: PITA reduced the odds of postoperative hemorrhage by 8.95% (odds ratio [OR]: 5.69, p = 0.013) and of secondary hemorrhage by 8.8% (OR: 10.08, p = 0.006), decreased postoperative analgesia use by 0.35% (p < 0.001), and increased oral intake on postoperative day 1 by 17% (p < 0.001). There were no significant differences in early hemorrhage or regrowth rates between the groups.
CONCLUSIONS: PITA could reduce the risk of secondary hemorrhage and improve postoperative quality of life, which are ideal clinical benefits of surgery in pediatric patients with OSA.

UNASSIGNED: The effects of adenoid hypertrophy (AH) and adenoidectomy on maximal bite force (MBF) in patients were evaluated by comparing them with healthy controls.
UNASSIGNED: A total of 118 children diagnosed with AH and undergoing adenoidectomy (Group A), and healthy controls (Group B) were included. The MBF and nasopharyngeal airway passage distance (NAPD) were recorded.
UNASSIGNED: There was a correlation between NAPD and MBF at the beginning of the study (r = -0.675 and p < 0.001). The initial mean MBF of Groups A and B were 318.37 ± 70.76 N and 344.04 ± 64.14 N, respectively (p = 0.041). However, there was no significant difference between the groups due to the increase in the MBF of Group A at 12 months (p = 0.165).
UNASSIGNED: The MBF may be negatively affected in proportion to decreased NAPD, and it could also be an indicator for monitoring the status of children with AH.

OBJECTIVE: To perform a case series analysis of the changes in the pulmonary artery systolic pressure (PASP), nasal inspiratory flow (NIF), upper airway volume, obstructive apnea/hypopnea index (OAHI), and the maxillomandibular three-dimensional (3D) morphology after adenotonsillectomy (T&A) of obstructive sleep apnea children (OSA).
METHODS: Retrospective assessment of files from 1002 children screened between 2012 and 2020 in a hospital-based mouth-breather referral center. From this universe, 15 obstructive sleep apnea children (7 females; 8 males), ages 4.1 to 8.9 years old (mean age of 5.4 years ± 1.3), who presented indications of tonsillectomy and/or adenoidectomy were selected. The complete baseline examination (T0) was carried out before T&A and a second complete examination (T1) was made 18.7-month follow-up after T&A (ranging from 12 to 30 months). Eleven patients were submitted to T&A, and four patients had indications but did not receive authorization for surgery from the public health system. According to the protocol of the outpatient clinic for OSA patients, Doppler echocardiography, polysomnography, rhinomanometry, and computed tomography imaging was performed at (T0) and (T1).
RESULTS: PASP decreased 16.6% after T&A. NIF increased more in T&A children (40.3%) than in non-T&A children (16.8%). The upper airway volume increased in T&A and non-T&A children, but greater volumetric gain (45.6%) was found in the nasopharynx of T&A patients. OAHI did not change in six T&A children (55%) and three non-T&A children (75%). The maxilla displaced downward and backward relative to the cranial base in six T&A children (55%) and two untreated children (50%). Nine of the T&A children (85%) and three untreated children (75%) presented extensive condylar growth and increased mandibular length. The qualitative 3D assessment showed similar morphological 3D changes in T&A and non-T&A patients.
CONCLUSIONS: Pulmonary artery systolic pressure decreased, nasal inspiratory flow increased, and nasopharynx volume increased following adenotonsillectomy, but obstructive apnea/hypopnea index and maxillomandibular morphology were similar in surgical and non-surgical patients.

Obstructive sleep apnoea (OSA) is a common indication for adenoidectomy and tonsillectomy in children. Traditional practice involves overnight admission to monitor for respiratory complications. However, there is a shift towards same-day discharge in selected patients. This systematic review aims to critically evaluate day-case criteria and safety in children with OSA undergoing adenotonsillectomy.
We performed a systematic search of EMBASE, Medline and the Cochrane library. All data collected were independently validated for accuracy. Quality assessment of included articles was performed. The protocol was registered with PROSPERO.
A total of 15 studies were included (10 731 patients). There was heterogeneity in methods used to ascertain OSA, day-case discharge criteria and lack of prospective discharge protocol. The proportion of children considered for planned day-case surgery ranged from 28.7%-100% based on individual criteria, with an average rate of successful same-day discharge of 96.1% in these patients. The reported rates of post-operative respiratory adverse events and need for airway intervention were 0%-27.3% and 0.4%-6.8%, respectively. There was no reported mortality. The studies were considered low to medium on quality assessment.
There is a lack of prospective data on day-case criteria and systematic assessment of post-operative complications in children with OSA undergoing adenoidectomy and tonsillectomy. However, current literature suggests that day-case surgery is safe in carefully selected patients. Better characterisation of patient-specific risk factors is needed to develop an optimal criteria-based timeline for safe discharge. This has the potential to improve confidence and uptake across units.