Treating sleep apnea in children with tonsillectomy

BALTIMORE - The only real health problem that 3-year-old Nicholas Salter had was the occasional sore throat.

Sometimes, it hurt so much that it was hard to swallow, which cut back on his appetite. And there was one more issue: "He'd snore so loudly you could hear him in his room from the top of the steps," said his mother, Jackie Salter.

After two cases of strep throat within a few weeks, doctors recommended a sleep study: hooking Nicholas up to monitors overnight to make sure he was breathing properly and getting enough rest. Sure enough, Nicholas was found to suffer from sleep apnea, a condition that stopped his breathing four times an hour.

So the boy's tonsils had to go.

Although the number of tonsillectomies performed in the United States has dropped sharply over the decades, the operation has made a rebound of sorts in recent years as an effective treatment for sleep apnea in children.

Baby boomers often had their tonsils - lymphoid tissues at the back of the throat - yanked if they had more than two or three sore throats within a few months. But doctors backed away from that practice in the 1980s, when research showed that sore throats among children eventually cleared up without the operation. Also, experts say, better antibiotics were resulting in fewer severe sore throats in the first place.

"More and more, we don't take tonsillectomies lightly," said Dr. Daniel Levy of Owings Mills, president-elect of the Maryland chapter of the American Academy of Pediatrics.

These days, doctors are more likely to remove a youngster's tonsils to correct obstructive breathing problems associated with sleep apnea - an ailment that doctors are diagnosing in children with increasing frequency.

The number of tonsillectomies dropped from 1.4 million in 1959 to 260,000 by 1987, according to the American Academy of Otolaryngology. Now the number has returned to as many as 400,000 a year, with much of the increase attributed to sleep apnea relief, the academy says.

Complication rates for tonsillectomies range from 1 percent to 6 percent, the most common side effects being dehydration and excessive bleeding. A child usually takes a week to recover. One patient in 40,000 will die from excessive bleeding, experts say.

Doctors also perform tonsillectomies on adults - often to clear the airway in cases of breathing problems brought on by sleep apnea or allergies. But the surgery more commonly is performed on youngsters.

In a majority of cases, surgeons also remove the adenoids - another set of lymphoid tissue in the roof of the mouth. Like tonsils, adenoids can become infected and obstruct the airway.

Other remedies for sleep apnea include a special sleep mask worn over the mouth that pumps air into the lungs, and surgery on the patient's teeth, jaw or palate to clear airway obstructions, said Dr. Jennifer Wiebke, a pulmonologist and sleep physician at the Riley Hospital for Children in Indianapolis.

But removing the tonsils and adenoids remains the most common option in children. "In patients with sleep apnea symptoms, our experience is that 75 percent of the time, there's a need for the adenoid and tonsils both being removed," Wiebke said.

"There was a period when opinions were sharply divided over when to do tonsillectomies. Some pediatricians said they shouldn't be done on anyone, and others seem to recommend it for just about everyone," said Dr. Jack L. Paradise, a leading tonsillectomy researcher in the 1980s at the University of Pittsburgh School of Medicine.

Decades ago, many doctors considered the tonsils as seeds for respiratory illnesses. If a child suffered a bout of sore throats, they usually came out.

"In the 1950s and '60s, it was a rite of passage. You'd get in line and get your tonsils out. There'd be cases where whole groups of brothers and sisters would go in together," said Dr. Richard Rosenfeld, director of pediatric otolaryngology at Long Island College Hospital in Brooklyn.

Rosenfeld credits Paradise and fellow researchers with helping to steer physicians away from wholesale tonsillectomies.

In one study, published in 1984 in the New England Journal of Medicine, Paradise compared the health of 187 children, some of whom had tonsillectomies and some of whom didn't. He found that during a three-year period, those who kept their tonsils stopped having throat infections anyway.

In a recent interview, the now-retired Paradise said sleep-related problems are "a perfectly legitimate reason" for a tonsillectomy. But he's convinced that doctors should remain cautious about the procedure.

"If my grandchildren needed it, I'd probably drag my feet a little longer on having it done," he said.

In a 2002 follow-up study, Paradise confirmed that his original findings were still valid. He also developed what are known as the Paradise Criteria for tonsillectomies.

They would limit the operation to children with seven or more well-documented sore throats in one year, five sore throats in each of two successive years, or three sore throats in each of three successive years.

The American Academy of Pediatrics has a slightly lower threshold - five sore throats in a year, according to Levy. The threshold might be lower if the sore throats are severe.

"The best and first question is, does the child snore like an adult? The second question is, does the child sleep peacefully?" Levy said.

Snoring is one symptom of apnea, but it isn't conclusive evidence. About 10 percent of all children snore, but only 1 percent to 3 percent have sleep apnea, experts say. Along with conducting sleep studies, doctors might X-ray the child's neck, which will detect any obstruction in the airway.

In a study of 78 youngsters with sleep problems published last month, Dr. Ronald Chervin, director of the University of Michigan Sleep Disorders Center, found that children slept better and had fewer problems with behavior and attention in the year after their tonsils and adenoids were removed at two Ann Arbor, Mich., hospitals.

Since his surgery, Nicholas Salter is less prone to the runny noses and colds that had troubled him. He no longer wakes up once or twice every night. The snoring is gone, and his appetite has picked up.