New hope for children with sleep apnea
Partial tonsillectomy cures problem that can leave kids fidgety,
unfocused.
"The child is fidgety, unfocused and frequently disruptive in school.
A clear-cut case of attention-deficit hyperactivity disorder, right?
Maybe not. There's a good chance the child's tonsils may be to blame. And the problem
can be corrected with a groundbreaking surgery that results in far less pain and
a much quicker recovery than traditional treatment.
Sleep apnea is a condition that causes interrupted breathing during the night. While
the problem is typically associated with adults, particularly overweight men, an
estimated 1 percent to 3 percent of all children may suffer from pediatric sleep
apnea, University of Michigan researchers say.
Although a restless night's sleep typically leaves adults feeling drained and listless
the next day, that's not the case with many children, says Dr. Timothy Hoban, a
pediatric sleep specialist at the University of Michigan Health System.
These children "may actually be inattentive, energetic or even hyperkinetic," Hoban
says.
And enlarged tonsils that interfere with air flow in the breathing passages are
frequently the cause of the interrupted sleep that leads to behavioral problems
during the day.
Now, a small group of doctors in six hospitals throughout the country is performing
what is called a "partial tonsillectomy" on children who have sleep apnea or other
breathing problems.
Rather than a traditional tonsillectomy, which includes the removal of the tonsil
and all the surrounding tissue, this procedure leaves a small layer of tonsil tissue
intact along the throat. This protects the throat muscles and dramatically reduces
the pain, bleeding and recovery time for the children, proponents say.
"We leave about 15 percent of the tissue in the throat so that no raw muscle is
exposed, which reduces bleeding, scarring and pain," says Dr. Max April, of Lenox
Hill Hospital in New York City, who with other doctors in his practice has performed
about 300 partial tonsillectomies since 2000.
Dr. Peter J. Koltai, an otolaryngologist at the Cleveland Clinic, pioneered the
operation in 1996, when trying to help a colleague's 1-year-old infant who had "enormous
tonsils, a large adenoid and documented sleep apnea."
"A tonsillectomy is a terribly difficult procedure for young children," Koltai says.
So, he thought of using on the child the same technique he used for removal of adenoids,
which is shaving them down with a special tool rather than cutting them out, leaving
a protective covering of tonsil tissue over the throat muscles.
The procedure is done on an out-patient basis, takes about 15 minutes and the results
are excellent, Koltai says, with immediate improvement in a child's breathing as
well as a relatively speedy recovery time.
He has performed about 400 of the operations to treat children's obstructed sleep
or disordered breathing, and says that post-operative bleeding has been reduced
by about half.
"Less pain medication is used, and children can resume their normal diet and normal
activities much more quickly," in about two to three days compared to seven to 10
days with a total tonsillectomy, Koltai says.
Koltai doesn't use the procedure on children with tonsillitis, for which a complete
tonsillectomy is the standard treatment. Tonsillitis is an infection in the tonsil
and its surrounding tissue; by not removing all the tissue, there's a risk of future
infection, he says.
"I am concerned that there could be tissue left that will become infected," Koltai
says, which would mean the child would need a second surgery.
Two of the children on whom Koltai performed partial tonsillectomies for sleep apnea
or breathing obstruction did have their tonsil tissue grow back and needed a second
operation. He says regrowth of tissue can happen to a small percentage of children,
even with total tonsillectomies.
However, the possible regrowth of tissue is a concern for some doctors who haven't
adopted the partial tonsillectomy technique.
"I have reservations, mainly that I don't know what the potential is for regrowth
of tissue, so that kids would be subjected to a second operation," says Dr. Earl
Harley, an associate professor of otolaryngology and pediatrics at Georgetown University
Hospital.
"If I were convinced that this would be a good operation, I'd do it. I'd love to
get kids up and back to school in a week, but there is no long-term data on the
procedure. The questions are still out there, and I just want to wait."
Koltai, April and the doctors who are performing the procedure in hospitals in other
cities - including Birmingham, Ala., Norfolk, Va., and Wilmington, Del. - are collecting
information on the procedures they've performed. And Koltai will present data on
700 partial tonsillectomies at the American Society of Pediatric Otolaryngology's
annual meeting in May in Nashville, Tenn.
"The standard has been when you do a tonsillectomy you take out the whole tonsil.
We are challenging that assumption, which is a deeply ingrained idea," says Koltai.
"But this is wonderful for the child.""