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Original Investigation |

Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea

Pamela Mukhatiyar, MD1; Kiran Nandalike, MD2; Hillel W. Cohen, DrPH, MPH3; Sanghun Sin, MS1; Mona Gangar, MD4; John P. Bent, MD4; Raanan Arens, MD1
[+] Author Affiliations
1Division of Pediatric Respiratory and Sleep Medicine, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
2Department of Pediatric Pulmonology, UC Davis Children’s Hospital, Sacramento, California
3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
4Department of Otolaryngology–Head and Neck Surgery, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
JAMA Otolaryngol Head Neck Surg. 2016;142(1):25-31. doi:10.1001/jamaoto.2015.2603.
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Importance  Limited information exists regarding clinical outcomes of children undergoing extracapsular tonsillectomy and adenoidectomy (ETA) or intracapsular tonsillectomy and adenoidectomy (ITA) for treatment of obstructive sleep apnea syndrome (OSAS).

Objectives  To quantify polysomnography (PSG) and clinical outcomes of ETA and ITA in children with OSAS and to assess the contribution of comorbid conditions of asthma and obesity.

Design, Setting, and Participants  Retrospective cohort study using medical records at a tertiary pediatrics inner-city hospital. Medical records from 89 children who underwent ETA or ITA between October 1, 2008, and December 31, 2013, were analyzed. The dates of our analysis were January 6, 2014, to April 11, 2014. Inclusion criteria required no evidence of craniofacial or neurological disorders, confirmation of OSAS by PSG within the 2 years before surgery, and a second PSG within the 2 years after surgery.

Interventions  Each child underwent ETA or ITA after being evaluated by a pediatric otolaryngologist and obtaining written parental informed consent.

Main Outcomes and Measures  Main primary outcomes were derived from PSG. Secondary outcomes included treatment failure, defined as residual OSAS with an obstructive apnea-hypopnea index of at least 5 events per hour. Comparisons were made between and within groups. Logistic regression was used to identify factors associated with treatment failure.

Results  Fifty-two children underwent ETA, and 37 children underwent ITA. Children in the ETA group were older (7.5 vs 5.2 years, P = .001) and more obese (60% [31 of 52] vs 30% [11 of 37], P = .004). However, both groups had similar severity of OSAS, with median preoperative obstructive apnea-hypopnea indexes of 17.0 in the ETA group and 24.1 in the ITA group (P = .21), and similar prevalences of asthma (38% [20 of 52] vs 38% [14 of 37]). After surgery, significant improvement was noted on PSG in both groups, with no differences in any clinical outcomes. There was no association between procedure type, age, or body mass index z score and treatment failure. However, in a subset of patients with asthma and obesity, ITA was associated with residual OSAS (odds ratio, 16.5; 95% CI, 1.1-250.2; P = .04).

Conclusions and Relevance  Both ETA and ITA are effective modalities to treat OSAS, with comparable surgical outcomes on short-term follow-up. However, when comorbid diagnoses of both asthma and obesity exist, OSAS is likely to be refractory to treatment with ITA compared with ETA.

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Figure.
Comparison of Preoperative and Postoperative oAHI in Patients Undergoing ETA and ITA

Box plots represent all patients; open circles and lines, individual patients; and closed circles, the mean oAHI. Diamonds indicate outliers. ETA indicates extracapsular tonsillectomy and adenoidectomy; ITA, intracapsular tonsillectomy and adenoidectomy; and oAHI, obstructive apnea-hypopnea index.

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